Nokea
The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- A. The UAP keeps the chest tube below chest level.
- B. The UAP has the chest tube attached to suction.
- C. The UAP allowed the client out of the bed.
- D. The UAP uses a bedside commode for the client.
Correct Answer: B
Rationale: Suction during ambulation (B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (A), ambulation (C), and commode (D) are appropriate.
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Which is the correct volume needed for the nurse to administer the prescribed dose of 0.1 mg of epinephrine to the client?
- A. 0.001 mL
- B. 0.1 mL
- C. 1.0 mL
- D. 10 mL
Correct Answer: B
Rationale: For a 1:1,000 epinephrine solution (1 mg/mL), a 0.1 mg dose equals 0.1 mL, calculated as 0.1 mg ÷ 1 mg/mL = 0.1 mL.
The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the 'Right to Know' law. Which information should the nurse include in the presentation? Select all that apply.
- A. A client who smokes cigarettes has a drastically increased risk for lung cancer.
- B. Floors need to be clean and dust needs to be wet to prevent transfer of dust.
- C. The air needs to be monitored at specific times to evaluate for exposure.
- D. Surface areas need to be painted every year to prevent the accumulation of dust.
- E. Employees should wear the appropriate personal protective equipment.
Correct Answer: A,B,C
Rationale: Smoking increases lung cancer risk (1), relevant to toxic exposures. Wet dust control (2) reduces airborne particles. Air monitoring (3) ensures safe exposure levels. PPE (5) is critical for protection. Annual painting (4) is not a standard dust control measure.
A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's?
- A. hearing
- B. mental status
- C. vitamin B6 level
- D. vision
Correct Answer: D
Rationale: This medication can cause inflammation of the optic nerve. Therefore, it is very important the nurse asks the patient about their vision. If the patient has blurred vision or reports a change in colors, the MD must be notified immediately.
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.
- A. Place the client on oxygen delivered by nasal cannula.
- B. Plan for periods of rest during activities of daily living.
- C. Place the client on a fluid restriction of 1,000 mL/day.
- D. Restrict the client's smoking to two (2) to three (3) cigarettes per day.
- E. Monitor the client's pulse oximetry readings every four (4) hours.
Correct Answer: B,E
Rationale: Rest periods (B) conserve energy, and pulse oximetry (E) monitors oxygenation in pneumonia. Oxygen (A) depends on SpO2, fluid restriction (C) is inappropriate, and smoking (D) must stop.