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When providing oral care for an unconscious client, which of the following actions should the nurse take?
- A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
- B. Insert a suction catheter before brushing the teeth.
- C. Use a soft-bristled toothbrush only with water.
- D. Brush the client's teeth while they are in a supine position.
Correct Answer: A
Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.
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The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?
- A. Place a pillow under the patient's lower legs.
- B. Turn the head toward one side with a large, soft pillow.
- C. Position legs flat against the bed.
- D. Raise the head of the bed to 45 degrees.
Correct Answer: A
Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.
When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?
- A. Lock the wheels on both the bed and stretcher
- B. Adjust the bed to a low position
- C. Ask the client to assist in the transfer
- D. Use a transfer sheet without locking the wheels
Correct Answer: A
Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.
When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?
- A. Use a car seat that has a three-point harness system.
- B. Position the car seat so that the infant is rear-facing.
- C. Secure the car seat in the front passenger seat of the vehicle.
- D. Convert to a booster seat after 12 months.
Correct Answer: B
Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?
- A. INR of 1.5
- B. Platelet count of 200,000/mm³
- C. Hemoglobin of 12 g/dL
- D. aPTT of 70 seconds
Correct Answer: A
Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.
A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. Constant bubbling in the suction control chamber
- B. Intermittent bubbling in the water seal chamber
- C. Drainage of 50 ml per hour
- D. Crepitus around the insertion site
Correct Answer: D
Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.