Nokea
A nurse is collecting a sputum specimen from a client who has tuberculosis.
Which of the following actions should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait 1 day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum in the container.
- D. Wear sterile gloves to collect specimen from the client.
Correct Answer: A
Rationale: The correct answer is A because obtaining the specimen immediately upon the client waking up is crucial for accurate results in sputum collection. In the morning, the sputum is usually more concentrated and provides a better sample. Waiting or collecting at other times may lead to diluted or contaminated samples, affecting test results. Choice B is incorrect as it suggests delaying collection, which could compromise the accuracy of the test. Choice C is incorrect because the amount specified is too high for sputum collection, risking contamination. Choice D is incorrect as sterile gloves are not always necessary for sputum collection, regular gloves are usually sufficient.
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A nurse is caring for a 9-year-old child at a clinic.
Nurses' Notes
1000:
Child has been brought to the clinic by their parent due to a report of right arm pain. The parent
states that several hours ago the child tripped and fell onto the sidewalk while playing
outside. The child states, "I was running when we were playing. and I tripped over a curb." Child
is supporting their arm across their body.
Assessment
Respirations easy and unlabored, Abdomen non-distended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation, Child
verbalizes a pain level of 4 on a scale of 0 to 10, Multiple areas of bruising are noted on lower
extremities in various stages of healing
Vital. Signs
Temperature 36.8°C (98.2° F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Nurse reviews the assessment findings. Which findings require immediate follow-up?
- A. Right forearm and fingers are edematous.
- B. Ecchymotic area noted on outer aspect of the forearm.
- C. Heart rate 102/min
- D. Fingers slightly cool to touch.
- E. Child verbalizes a pain level of 4 on a scale of 0 to 10
- F. Respiratory rate 22/min
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication.
Which of the following interventions should the nurse include in the plan?
- A. Speak in a neutral tone when addressing the client.
- B. Force the client to take the prescribed medication.
- C. Encourage the client to discuss their delusions.
- D. Use humor to lighten the mood and build trust.
Correct Answer: A
Rationale: The correct answer is A: Speak in a neutral tone when addressing the client. This intervention is important as it helps maintain a calm and non-threatening environment, promoting effective communication with the client. Speaking in a neutral tone also conveys respect and understanding, which can help build trust and rapport.
Choice B is incorrect because forcing the client to take medication can lead to resistance and worsen the therapeutic relationship. Choice C may not be appropriate as encouraging a client to discuss delusions without proper training or expertise in addressing such issues could potentially exacerbate the situation. Choice D, using humor, may not be suitable in this context as it may not be well received by a client experiencing delusions.
A nurse manager is addressing reports of conflict within a nursing unit.
The nurse should identify which of the following situations as an example of interpersonal conflict?
- A. A nurse submits a complaint about another department's handoff reporting.
- B. A nurse feels stressed about an upcoming performance evaluation.
- C. A hospital policy change leads to disagreements among staff members.
- D. Two nurses disagree on how to handle a client's care plan.
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between two individuals, which is a key characteristic of interpersonal conflict. In this scenario, the conflict arises between two nurses regarding the client's care plan, indicating a disagreement in opinions or approaches. This type of conflict typically involves differences in perspectives, values, or goals between individuals. Choices A, B, and C do not involve direct conflicts between individuals but rather focus on complaints, stress, and policy disagreements that do not necessarily involve direct interpersonal conflicts. Therefore, option D is the most appropriate example of interpersonal conflict in this context.
The nurse is continuing to care for the child.
Assessment
1000:
Child is alert and appears developmentally appropriate for their age and well nourished.
Respirations easy and unlabored. Abdomen nondistended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child
verbalizes a pain level of 4 on a scale of 0 to 10. Abrasion noted on right knee. No active
bleeding. Multiple areas of bruising noted on lower extremities in various stages of healing.
Complete the sentence using the lists of options.The child is at highest risk for developing------------evidenced by the child's-----------
- A. compartment syndrome
- B. circulatory impairment
- C. abrasion and bruising
- D. paresthesia
- E. nerve damage
Correct Answer: B,D
Rationale: Circulatory impairment is evidenced by paresthesia (tingling), indicating compromised blood flow.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.