Nokea
The nurse supervises a student nurse preparing a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student
- A. Asks the client if they have claustrophobia.
- B. Instructs the client to apply earplugs before the exam.
- C. Moves the nitroglycerin patch from the torso to the back.
- D. Tells the client that they will not have any exposure to radiation.
Correct Answer: C
Rationale: Moving a nitroglycerin patch can disrupt medication delivery and is unnecessary for MRI. Asking about claustrophobia, using earplugs, and confirming no radiation exposure are correct.
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The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
- A. Applies clean gloves to cleanse the perineal area with soap and water.
- B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
- C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
- D. Secures the catheter tubing to the inner thigh.
- E. Attaches the drainage bag to the side rails of bed.
Correct Answer: A,C,E
Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.
Which of the following actions is most effective at reducing the incidence of health-care-associated infections?
- A. Screen all newly admitted clients for colonization or infection with MRSA.
- B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms.
- C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
- D. Require nursing staff to wear gowns to change wound dressings for all clients.
Correct Answer: C
Rationale: Alcohol-based hand rub availability is the most effective way to reduce healthcare-associated infections by promoting frequent hand hygiene. MRSA screening, automatic antibiotics, and universal gown use are less effective or inappropriate.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
The nurse is discussing negligence with a new nurse. Which of the following situations can the nurse use as an example of negligence?
- A. The Unlicensed Assistive Personnel (UAP) fills a water basin with warm water while the client with depression combs their hair.
- B. A nurse transcribes a new medication order: Cholestyramine powder 2 oz bid with wet food or one full glass of water.
- C. The nurse first checks the distal pulses of a client's legs two hours after they have returned from a cardiac catheterization.
- D. The nurse observes a UAP enter the room of a client on contact precautions wearing gloves and a gown.
Correct Answer: NONE
Rationale: None of the options describe negligence, as all reflect appropriate actions or minor procedural variations without harm.
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.