Nokea
Which of the following must NOT be included in an incident or accident form or report?
- A. The name of the person completing the report.
- B. The name of the client and if anyone was injured.
- C. The location of the incident or accident.
- D. An explanation of what may have led to the incident.
Correct Answer: NONE
Rationale: All listed elements are typically required in an incident report to ensure accurate documentation and follow-up.
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The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?
- A. A doppler
- B. A surgical vein cut down
- C. A transillumination device
- D. A sonography
Correct Answer: C
Rationale: A transillumination device uses light to visualize veins, aiding IV insertion in clients with dark skin or poor vein visibility. Doppler assesses blood flow, surgical cutdown is invasive, and sonography is not typically used for peripheral IVs.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse is preparing to insert a nasogastric tube (NGT) for a client with abdominal distention. The nurse should place the client in which position for this procedure?
- A. Supine with the head of the bed elevated at 30 degrees
- B. Supine with the head of the bed 90 degrees
- C. Left-lateral position with the knees bent
- D. Right-lateral position with the knees bent
Correct Answer: B
Rationale: A 90-degree head-of-bed elevation facilitates NGT insertion by aligning the esophagus and reducing aspiration risk. Other positions are less effective.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.