Nokea
What is the first step a healthcare professional should take when preparing to provide tracheostomy care?
- A. Perform hand hygiene
- B. Gather equipment
- C. Explain the procedure
- D. Assess the client
Correct Answer: A
Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.
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A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Administer the medication with the needle at a 30-degree angle.
- D. Administer the medication with the needle at a 15-degree angle.
Correct Answer: B
Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.
A client with diabetes mellitus is being taught by a nurse how to perform a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching?
- A. Don sterile gloves after cleansing the site
- B. Puncture the site after cleansing and before the antiseptic dries
- C. Gently wipe the puncture site until a large droplet of blood forms
- D. Hold the finger below the heart level to puncture
Correct Answer: B
Rationale: The correct instruction is to puncture the site after cleansing and before the antiseptic dries. This sequence helps ensure proper blood collection without introducing contaminants. Choice A is incorrect because wearing sterile gloves is not necessary for capillary blood glucose testing. Choice C is incorrect as wiping the puncture site can introduce contaminants and alter the blood sample. Choice D is incorrect as holding the finger below the heart level is not required for a capillary blood glucose test.
The client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the healthcare provider monitor closely?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct Answer: A
Rationale: Correct! When a client is taking furosemide (Lasix), monitoring potassium levels is crucial due to the potential for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Low potassium levels can predispose the client to cardiac dysrhythmias. Sodium, calcium, and magnesium levels are not typically affected by furosemide to the same extent as potassium, making them less critical to monitor in this scenario.
Which goal is most appropriate for a patient who has had a total hip replacement?
- A. The patient will ambulate briskly on the treadmill by the time of discharge.
- B. The patient will walk 100 feet using a walker by the time of discharge.
- C. The nurse will assist the patient to ambulate in the hall 2 times a day.
- D. The patient will ambulate by the time of discharge.
Correct Answer: B
Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.
A healthcare professional is supervising the logrolling of a patient. To which patient is the healthcare professional most likely providing care?
- A. A patient with neck surgery
- B. A patient with hypostatic pneumonia
- C. A patient with a total knee replacement
- D. A patient with a stage IV pressure ulcer
Correct Answer: A
Rationale: Logrolling is a technique used to move a patient as a single unit to prevent twisting or bending of the spine. Patients who have undergone neck surgery require special care to ensure the spinal column remains in straight alignment to prevent further injury. Therefore, the correct answer is a patient with neck surgery. Choice B, a patient with hypostatic pneumonia, does not require logrolling, as it is a condition affecting the lungs, not the spine. Choice C, a patient with a total knee replacement, does not typically necessitate logrolling, as the procedure focuses on the knee joint, not the spine. Choice D, a patient with a stage IV pressure ulcer, requires wound care but does not necessarily involve logrolling unless the ulcer is located in a critical area that requires special handling.