Nokea
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.
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The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.
The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply.
- A. Place a gait belt around the client's waist.
- B. Stand on the client's left side during ambulation.
- C. Instruct the client to put the cane in the left hand.
- D. Measure the cane from the client's wrist crease.
- E. Instruct the client to put the cane in the right hand.
- F. Instruct the client to look down while ambulating.
Correct Answer: A,B,E
Rationale: A gait belt ensures safety, standing on the weaker side provides support, and the cane in the right hand aids balance. Cane height is measured to the greater trochanter, and looking down risks falls.
The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up?
- A. Advances the tube during the client's inspiration.
- B. Hands the client a cup of water and straw.
- C. Positions the client's head-of-bed at 90 degrees.
- D. Washes the client's bridge of nose with soap and water.
Correct Answer: A
Rationale: Advancing an NGT during inspiration increases the risk of tracheal placement. Providing water, elevating the bed to 90 degrees, and cleaning the nose are appropriate actions.
The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
- A. boot (shoe) covers
- B. face shield
- C. surgical mask
- D. gown
Correct Answer: C
Rationale: Haemophilus influenzae, type b meningitis requires droplet precautions, which include wearing a surgical mask when within 3 feet of the client. Boot covers, face shields, and gowns are not specifically required unless additional risks (e.g., splashing) are present.
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.