Nokea
Which of the following actions should the nurse take?
- A. Keep visitors at least 6 feet(1.8 m) away from the client.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room.
- C. Wear an isolation gown when caring for the client.
- D. Discard the radioactive source in the client's trash can.
Correct Answer: B
Rationale: The correct answer is B: Place the client's soiled bed linens in a biohazard bag outside the client's room. This is the correct action to prevent the spread of infection, as soiled linens may contain infectious agents. Keeping visitors 6 feet away (choice A) is related to social distancing, not linens handling. Choice C, wearing an isolation gown, is important but not directly related to handling soiled linens. Discarding a radioactive source in the trash can (choice D) is unsafe and violates radiation safety protocols.
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Which of the following findings should the nurse expect?
- A. Reduce right sided breath sounds
- B. Inter coastal retractions
- C. High pitched strider
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not characteristic of pneumothorax.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.