Nokea
The quality and risk nurse in the local hospital is performing a hospital survey
on sentinel events. Which statements would the nurse use to best describe a
sentinel event?
- A. Operating room event involving the use of unsafe equipments
- B. Specific events that enable a hospital to maximize reimbursement
- C. An unexpected event involving death or serious physical or psychological injury
- D. An event that can cause serious injury to a client that should never happen in a
hospital
Correct Answer: C
Rationale:
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The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct Answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
A nurse is caring for a client who has acute osteomyelitis. Which of the
following interventions is the nurse's priority?
- A. Administer antibiotics to the client
- B. Increase the client's protein intake
- C. Teach relaxation breathing to reduce the client's pain
- D. Provide the client with anti-pyretic therapy
Correct Answer: A
Rationale:
What is an example of a client's primary defense to infection?
- A. Intact skin
- B. Inflammation
- C. Phagocytosis
- D. Fever
Correct Answer: A
Rationale:
A client is immobile and requires mechanical ventilation with a tracheostomy.
She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse
observes bone and tendon at the base of the wound. How would the nurse
document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct Answer: D
Rationale:
A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct Answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.