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.
You may also like to solve these questions
The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed?
- A. using dedicated client-care equipment for a client with Clostridium difficile.
- B. wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
- C. placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
- D. keeping the door closed for a client with cryptococcal meningitis.
Correct Answer: A
Rationale: Dedicated equipment for C. difficile prevents transmission. N95 is not needed for epiglottitis, masks are not required for mononucleosis transport, and cryptococcal meningitis does not require a closed door.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.
The nurse is observing a student prepare to perform a sterile procedure. Which action by the student would require follow-up? The student
- A. reaches over the sterile field to grab sterile gloves.
- B. establishes the sterile field on a dry surface.
- C. uses slow movements when setting up sterile drapes.
- D. keeps the sterile field at their waist level.
Correct Answer: A
Rationale: Reaching over the sterile field risks contamination and requires follow-up.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.