Nokea
When should healthcare professionals perform hand hygiene?
- A. Before and after patient contact
- B. Before and after performing procedures
- C. After using the restroom
- D. After touching contaminated surfaces
Correct Answer: A
Rationale: Healthcare professionals should perform hand hygiene before and after patient contact to prevent the spread of infections. While choices B, C, and D are also important times to practice hand hygiene, they are not as crucial as before and after patient contact because patient contact poses a higher risk of transmitting infections.
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What is the best way to assess a patient's respiratory function after surgery?
- A. Check oxygen saturation
- B. Auscultate lung sounds
- C. Check for abnormal breath sounds
- D. Check skin color
Correct Answer: A
Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.
A nurse is assessing a client who is 2 hours postoperative following a gastrectomy. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 94/min
- B. Oxygen saturation of 88%
- C. Respiratory rate of 18/min
- D. Temperature of 37.6°C (99.7°F)
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.
What is the best intervention for a patient experiencing hypoxia?
- A. Administer oxygen
- B. Reposition the patient
- C. Provide humidified air
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.
A healthcare professional is reviewing laboratory results for a client who has cirrhosis. Which of the following findings should the professional report to the provider?
- A. Albumin 3.5 g/dL
- B. Bilirubin 1.0 mg/dL
- C. INR 3.0
- D. Ammonia 80 mcg/dL
Correct Answer: C
Rationale: An INR of 3.0 is elevated, indicating impaired blood clotting function, which poses a significant risk of bleeding in clients with cirrhosis. This finding should be promptly reported to the provider for further evaluation and management.
Choice A (Albumin 3.5 g/dL) is within the normal range and indicates adequate liver synthetic function, so it does not require immediate reporting. Choice B (Bilirubin 1.0 mg/dL) is also within the normal range and typically seen in clients without significant liver dysfunction, so it does not need urgent attention. Choice D (Ammonia 80 mcg/dL) is elevated, but it is not the priority finding in cirrhosis; elevated ammonia levels are associated with hepatic encephalopathy rather than increased bleeding risk.
What is the most important nursing action when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.