Nokea
Which action by a graduate nurse would require the charge nurse to intervene?
- A. Walking in the hallway outside the operating room without a hair covering
- B. Putting on a surgical mask, gown, and cap before entering the operating room
- C. Wearing a surgical mask into the holding area
- D. Wearing scrubs from home into the nursing station
Correct Answer: A
Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.
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A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
- A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
- B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
- C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
- D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.
Correct Answer: C
Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.
For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
- A. Headache
- B. Pruritus
- C. Vomiting
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.
A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:
- A. Obtaining Intake and Output.
- B. Frequent lung assessments.
- C. Vital signs every shift.
- D. Monitoring the IV site for infiltration.
Correct Answer: D
Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.
The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct Answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
The power a healthcare professional exerts when working to accomplish goals and effect change in an agency or policy is considered what type of power?
- A. political
- B. personal
- C. positional
- D. professional
Correct Answer: A
Rationale: Political power is the correct answer in this scenario. It stems from the ability to navigate systems, agencies, or policies to bring about change. Personal power is related to charisma and self-confidence in informal leadership roles. Positional power comes from holding a specific authority in a formal position. Professional power is derived from expertise in a particular area of practice. Therefore, in the context of effecting change in an agency or policy, political power is the most relevant type of power.