Nokea
When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?
- A. Clamp the tube close to the client's chest until a new chest drainage unit is set up
- B. Notify the health care provider
- C. Place the distal end of the chest tube into a bottle of sterile saline
- D. Position the client on the left side
Correct Answer: C
Rationale: Placing the distal end of the chest tube in sterile saline maintains a water seal, preventing air from entering the pleural space until a new drainage unit is prepared.
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The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?
- A. I can tell that you want me to go, so I will call in a few days to see how you are doing.
- B. I know you are frustrated with losing control of your life.
- C. It sounds like you are angry. Tell me what's bothering you.
- D. Okay. I'll just check your blood pressure and then go.
Correct Answer: C
Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.
A client undergoes cryosurgery for the removal of a basal cell carcinoma on the ear. Which of the following best describes the appearance of the area a few days after surgery?
- A. It's dry, crusty, and itchy.
- B. It's oozing and painful.
- C. It's dry and tender.
- D. It's swollen, tender, and blistered.
Correct Answer: A
Rationale: Post-cryosurgery, the treated area typically forms a dry, crusty scab and may be itchy as it heals.
A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of time-out
- D. Explain that the child needs extra attention
Correct Answer: B
Rationale: Explain that this behavior is expected. Fear of strangers is normal in toddlers and extends into the preschool period.