Nokea
When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?
- A. Place sterile items around the sterile field
- B. Keep hands below waist level to avoid contamination
- C. Open the sterile package away from the body
- D. Avoid reaching over the sterile field
Correct Answer: D
Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.
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When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?
- A. Close the doors to all residents' rooms
- B. Offer comfort and reassurance to each resident
- C. Identify the method for transporting and evacuating each resident
- D. Provide blankets to each resident for use during evacuation
Correct Answer: C
Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.
After spinal fusion surgery, a client reports numbness and tingling in the legs. What should the nurse do first?
- A. Assess the client's neurovascular status in the lower extremities.
- B. Reposition the client to relieve pressure on the spine.
- C. Administer prescribed pain medication.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: After spinal fusion surgery, numbness and tingling in the legs may indicate nerve compression or damage. The priority action for the nurse is to assess the client's neurovascular status in the lower extremities. This assessment will help determine the cause and severity of the symptoms, guiding further interventions. Repositioning the client may be necessary for comfort, but assessing neurovascular status is the initial step. Administering pain medication should only follow the assessment to address any discomfort. Notifying the healthcare provider immediately is not the first action unless there are emergent signs requiring urgent intervention.
A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?
- A. Encourage the client to drink fluids.
- B. Assist the client back to bed and monitor vital signs.
- C. Administer a prescribed antiemetic.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The nurse's priority action should be to assist the client back to bed and monitor vital signs. The client's symptoms of feeling weak and lightheaded could indicate potential issues like hypotension or dehydration, which need to be assessed promptly. Encouraging fluids (Choice A) could be beneficial but is not the immediate priority. Administering an antiemetic (Choice C) may not address the underlying cause of the client's symptoms. Notifying the healthcare provider (Choice D) can be done after the client has been stabilized and assessed.
Which of the following is a common side effect of opioid analgesics that the nurse should monitor for in patients?
- A. Diarrhea
- B. Hypertension
- C. Constipation
- D. Bradycardia
Correct Answer: C
Rationale: Constipation is a common side effect of opioid analgesics due to the slowing of gastrointestinal motility. Opioids bind to receptors in the gastrointestinal tract, leading to decreased peristalsis and increased water absorption, resulting in constipation. Monitoring for constipation is crucial to prevent discomfort or complications like bowel obstruction. Diarrhea (Choice A) is not a common side effect of opioid analgesics. Hypertension (Choice B) and Bradycardia (Choice D) are not typically associated with opioid use.
During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding?
- A. Increase intake of dried peaches and apricots
- B. Reduce intake of red meats
- C. Encourage use of a soft toothbrush
- D. Force fluid intake to 1500 mL daily
Correct Answer: A
Rationale: The correct answer is to recommend increasing the intake of dried peaches and apricots. A serum potassium level of 3.0 mEq/L is considered low. Increasing the intake of potassium-rich foods can help raise the serum potassium level, preventing complications such as muscle weakness and cardiac arrhythmias. Choice B, reducing intake of red meats, is incorrect because red meats are not specifically related to potassium levels. Choice C, encouraging the use of a soft toothbrush, is unrelated to addressing low potassium levels. Choice D, forcing fluid intake to 1500 mL daily, is not the appropriate intervention for low serum potassium; instead, increasing potassium-rich foods is more beneficial.