Nokea
Laboratory reference ranges
WBCs
5000–10,000/mm3
(5–10 × 109/L)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L)
Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Client admitted with WBC count of 28,000 mm3 (28.0 x 109/L) and dies from sepsis
- B. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine
- C. Client refuses pneumonia vaccination and contracts pneumonia
- D. Nurse did not report client's new hemoglobin result of 6.0 g/dL (60 g/L) to oncoming nurse
- E. Provider was not notified of client's positive blood culture results
Correct Answer: B,D,E
Rationale: Medication error , failure to report hemoglobin , and failure to notify about blood culture are reportable adverse events. Sepsis death and vaccine refusal are not necessarily preventable errors.
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Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.
A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client?
- A. Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs
- B. Client will be ready for sexual activity after completion of cardiac rehabilitation
- C. It will be 6 months before the heart is healthy enough for sexual activity
- D. Medications such as sildenafil or tadalafil are available as prescriptions from the health care provider
Correct Answer: A
Rationale: Climbing two flights of stairs without symptoms indicates sufficient cardiac reserve for sexual activity. Waiting for rehab completion or 6 months is unnecessary, and medications require provider discussion.
An adult postoperative client vomits, and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- A. Cover the exposed coils of intestine with sterile moist towels or dressings
- B. Pack the intestines back into the abdominal cavity
- C. Irrigate the exposed coils of intestines with sterile water
- D. Take the client's vital signs
Correct Answer: A
Rationale: Covering exposed intestines with sterile moist dressings prevents infection and drying of tissue, stabilizing the client until surgical intervention. Packing intestines risks contamination, irrigation is inappropriate, and vital signs are secondary to immediate protection.
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
The nurse is observing a staff member caring for a client who had a vaginal birth 30 minutes ago. The client is having difficulty with breastfeeding and is requesting assistance. The nurse should intervene if the staff member is observed
- A. providing supplemental formula feedings until improved breastfeeding occurs
- B. checking the newborn's position and sucking behavior during breastfeeding
- C. demonstrating to the client how to express breastmilk using the hand
- D. providing information on recognizing newborn hunger cues
Correct Answer: A
Rationale: Supplemental formula may undermine breastfeeding efforts early on. Checking position , demonstrating expression , and teaching hunger cues support breastfeeding.