Nokea
The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
- A. Remove identifying information of the clients who participated
- B. Recall that authored content may be legally discoverable
- C. Share material from credible, peer-reviewed sources only
- D. Respect all copyright laws when adding website content
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Therefore, documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care.
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?
- A. Ask the wife how she would like to participate in the client's care.
- B. Provide the wife with information about hospice.
- C. Encourage the wife to visit during and after painful treatments are completed.
- D. Refer the wife to a support group for family members of those dying of cancer.
Correct Answer: A
Rationale: During this difficult time of coping with terminal cancer diagnosis, involving the wife in the care process can help her feel more in control and connected. This can be beneficial for both the client and his wife, as it fosters a collaborative approach to care and ensures the wife's needs and preferences are considered.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- A. 75 ml/hr
- B. 150 ml/hr
- C. 225 ml/hr
- D. 300 ml/hr
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain in a lateral position using protective wrist and vest restraints.
- B. Position prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer to a wheelchair close to the nursing station for observation.
Correct Answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.