Nokea
What are the correct steps used for abdominal assessment?
- A. Inspection, auscultation, percussion, palpation
- B. Palpation, inspection, auscultation, percussion
- C. Percussion, palpation, inspection, auscultation
- D. Auscultation, palpation, percussion, inspection
Correct Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.
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A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses an alcohol-based hand rub for 30 seconds.
- C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
- D. The nurse washes her hands with soap and water for only 15 seconds.
Correct Answer: A
Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.
The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.
An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response?
- A. You should comply with the request
- B. You seem worried. Are you concerned someone may see you without your teeth?
- C. I will call your family to discuss this
- D. It's not a big deal; just remove them
Correct Answer: B
Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.
A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?
- A. Blood glucose of 350 mg/dL
- B. Serum bicarbonate of 18 mEq/L
- C. Arterial pH of 7.20
- D. Serum potassium of 5.5 mEq/L
Correct Answer: C
Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct Answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.