Nokea
Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure
- B. Instruct the client to avoid coughing during the procedure
- C. Inform the client that he will be NPO for 6 hr prior to the procedure
- D. Place the client in the prone position during the procedure,
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to avoid coughing during the procedure. This is crucial because coughing can disrupt the procedure, leading to potential complications. Coughing can cause movement that may interfere with the accuracy of the procedure or cause injury to the client. Positioning the client on the affected side (A) for 4 hours following the procedure is not necessary and can lead to discomfort. Informing the client that they will be NPO for 6 hours prior to the procedure (C) may not be relevant depending on the type of procedure. Placing the client in the prone position during the procedure (D) can be risky and uncomfortable for the client.
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Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A noncoring needle
Correct Answer: D
Rationale: The correct answer is D: A noncoring needle. The nurse should use a noncoring needle to access the port because it is specifically designed for this purpose. Noncoring needles have a special tip that minimizes damage to the port septum, reducing the risk of complications such as infection or port damage. An angiocatheter (A) is not ideal for accessing a port as it is designed for venipuncture, not for accessing ports. A 25-gauge needle (B) may be too small and may not provide adequate flow. A butterfly needle (C) is not recommended for accessing ports due to its design and potential for septum damage.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin.
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: A
Rationale: Correct Answer: A: Ensure the state health department has been notified.
Rationale:
1. Lyme disease is a reportable infectious disease, so notifying the state health department is crucial for tracking and controlling its spread.
2. Reporting to the health department allows for proper surveillance and monitoring of the disease in the community.
3. By notifying the health department, appropriate public health interventions can be implemented to prevent further cases.
Summary of Incorrect Choices:
B: Administer antitoxin - Lyme disease is caused by a bacterium, not a toxin, so antitoxin administration is not appropriate.
C: Educate the family to avoid sharing personal belongings - While important for hygiene, it does not directly address the management of Lyme disease.
D: Assess for skin necrosis - Skin necrosis is not a common manifestation of Lyme disease, so this action is not a priority in caring for a child with Lyme disease.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Which of the following Instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. This instruction is important to prevent complications such as blood clots and muscle stiffness post-procedure. Range-of-motion exercises help maintain joint flexibility and circulation. Choice A is incorrect as prolonged bed rest can increase the risk of blood clots. Choice C is important but not as crucial immediately post-procedure compared to mobilizing joints. Choice D is a comfort measure and does not have direct implications for post-procedure complications.