Nokea
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
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The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.
While starting a peripheral vascular access device (VAD) on a client, the nurse suffers a needlestick injury. Which action should the nurse take?
- A. Ask the client if they have the hepatitis A virus.
- B. Wash the affected extremity with soap and water.
- C. Document the incident in the client's medical record.
- D. Discontinue the vascular access device.
Correct Answer: B
Rationale: Washing with soap and water is the initial action to reduce infection risk after a needlestick.
The nurse is caring for a client who has rubella. To prevent the spread of infection, which transmission-based precaution should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: Rubella requires droplet precautions due to respiratory transmission.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
The nurse is preparing to insert a nasogastric tube (NGT) for a client with abdominal distention. The nurse should place the client in which position for this procedure?
- A. Supine with the head of the bed elevated at 30 degrees
- B. Supine with the head of the bed 90 degrees
- C. Left-lateral position with the knees bent
- D. Right-lateral position with the knees bent
Correct Answer: B
Rationale: A 90-degree head-of-bed elevation facilitates NGT insertion by aligning the esophagus and reducing aspiration risk. Other positions are less effective.