Nokea
Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest?
- A. Soak the intubation equipment in concentrated Betadine solution.
- B. Place the intubation blade in a bag and arrange for gas sterilization.
- C. Soak the intubation blade in Cidex solution.
- D. Wash the equipment with soap and water and allow to air-dry.
Correct Answer: B
Rationale: Gas sterilization ensures intubation equipment is pathogen-free, critical after exposure to body fluids. Options A, C, and D are inadequate for sterilization.
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The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
- A. Heart rate of 128
- B. Respiratory rate of 72
- C. Hematocrit of 50%
- D. Blood glucose of 60 mg/100 mL
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
The nurse is teaching a client with a new diagnosis of multiple sclerosis about interferon beta-1a (Avonex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or flu-like symptoms
- C. Stop the medication if symptoms improve
- D. Avoid regular neurological exams
Correct Answer: B
Rationale: Fever or flu-like symptoms are common interferon beta-1a side effects but may also indicate infection, requiring reporting. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and exams are essential.
The nurse is preparing to administer a medication to a client via a nasogastric tube. Which of the following actions should the nurse perform FIRST?
- A. Check the placement of the nasogastric tube.
- B. Crush the medication and mix with water.
- C. Flush the tube with 30 mL of water.
- D. Position the client in a supine position.
Correct Answer: A
Rationale: Verifying nasogastric tube placement prevents aspiration, a priority before medication administration. Options B, C, and D follow placement confirmation.
During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.