Nokea
The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?
- A. The development of an infection
- B. Hemorrhage
- C. Wound dehiscence
- D. Hematoma
Correct Answer: B
Rationale: Tachycardia with low blood pressure suggests hemorrhage, a life-threatening complication requiring immediate attention. Infection, dehiscence, and hematoma are less acute.
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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.
The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?
- A. P: 109; R: 26; BP: 110/70 mmHg
- B. P: 90; R: 12; BP: 99/54 mmHg
- C. P: 100; R: 18; BP: 161/98 mmHg
- D. P: 88; R: 14; BP: 166/52 mmHg
Correct Answer: B
Rationale: BP 99/54 mmHg indicates hypotension, requiring immediate follow-up. Tachycardia/tachypnea, hypertension, and wide pulse pressure are concerning but less urgent.
The nurse is preparing to administer intravenous chemotherapy to a client with cancer. While preparing the infusion in the client's room, the bag rips and leaks on the floor. The nurse should initially?
- A. obtain a chemotherapy spill kit.
- B. evacuate the client from the area.
- C. complete an incident report.
- D. request guidance from the pharmacy.
Correct Answer: A
Rationale: A chemotherapy spill kit is the initial action to safely clean hazardous material.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?
- A. Assess the client's level of consciousness
- B. Examine the client for injuries
- C. Call the rapid response team (RRT)
- D. Palpate the client's carotid pulse
Correct Answer: A
Rationale: Assessing the level of consciousness is the initial action to determine the client's neurological status and guide further interventions after a fall.