Nokea
What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
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A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which of the following statements by the nurse will be most helpful to the client?
- A. I have a special medication to decrease secretions.
- B. Avoid fluid intake 2 hours before sexual activity.
- C. Place a thin piece of gauze over the tracheostomy.
- D. Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity.
Correct Answer: C
Rationale: Placing a thin gauze over the tracheostomy can absorb secretions, reducing embarrassment and enabling the client to engage in sexual activity comfortably.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.
A client with a suspected small bowel obstruction reports severe pain and vomiting. Which diagnostic test should the nurse prepare the client for first?
- A. Abdominal X-ray.
- B. Barium enema.
- C. Colonoscopy.
- D. CT scan.
Correct Answer: A
Rationale: An abdominal X-ray is typically the first diagnostic test for a suspected small bowel obstruction to identify air-fluid levels or free air. Barium enema and colonoscopy are contraindicated in acute obstruction, and a CT scan may follow for detailed imaging. CN: Reduction of risk potential; CL: Synthesize
The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?
- A. Inserts the needle, bevel up at a 15-degree angle
- B. Instructs the client that the test will be read in 48-72 hours
- C. Selects a site 3 to 4 finger widths below the antecubital space
- D. Administers the test using a 20-gauge needle, 2 inches long
Correct Answer: D
Rationale: A PPD test requires a 26- or 27-gauge needle, 1/2 inch long, for intradermal administration.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.