Nokea
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
- A. Demonstrate the correct technique for giving a bed bath.
- B. Encourage the UAP to put the bed in the lowest position.
- C. Instruct the UAP to get another person to help with the bath.
- D. Provide praise for performing the bath safely for the client and the UAP.
Correct Answer: B
Rationale: Lowering the bed (B) prevents falls, critical for ARDS patients. Demonstration (A), extra help (C), and praise (D) are inappropriate given safety concerns.
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Which assessment technique is essential before allowing a client food or fluids after a bronchoscopy?
- A. Touch the arch of the palate with a tongue blade.
- B. Listen to the abdomen for active bowel sounds.
- C. Inspect the oral mucous membranes for integrity.
- D. Palpate the throat while the client swallows.
Correct Answer: D
Rationale: Palpating the throat while the client swallows confirms the gag reflex has returned, ensuring safe oral intake post-bronchoscopy.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply.
- A. Place the client in the low Fowler's position.
- B. Assess chest tube drainage system frequently.
- C. Maintain strict bedrest for the client.
- D. Secure a loop of drainage tubing to the sheet.
- E. Observe the site for subcutaneous emphysema.
Correct Answer: B
Rationale: Frequent system checks (B), securing tubing (D), and monitoring emphysema (E) ensure chest tube function. Low Fowler’s (A) is incorrect (semi-Fowler’s preferred), and bedrest (C) is unnecessary.
If a client is allergic to penicillin, the nurse should anticipate a hypersensitivity response to which other group of antibiotics?
- A. Aminoglycosides such as kanamycin (Kantrex)
- B. Tetracyclines such as doxycycline (Vibramycin)
- C. Cephalosporins such as ceftriaxone (Rocephin)
- D. Fluoroquinolones such as ciprofloxacin (Cipro)
Correct Answer: C
Rationale: Cephalosporins have a similar beta-lactam structure to penicillin, increasing the risk of cross-reactivity in penicillin-allergic clients.
Which of the following best indicates that the client's grief is beginning to resolve?
- A. The client wants only the spouse to visit.
- B. The client says the physician made an incorrect diagnosis.
- C. The client looks at the tracheostomy tube in a mirror.
- D. The client asks the nurse for help with bathing.
Correct Answer: C
Rationale: Looking at the tracheostomy tube in a mirror suggests acceptance of the body image change, indicating progress in resolving grief.