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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.
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A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. 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. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A because when setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come in contact with the solution, remains sterile. Placing the cap sterile-side up prevents contamination and maintains the integrity of the sterile field.
Choices B, C, and D are incorrect. Placing sterile gauze over spilled solution does not address the primary concern of maintaining sterility. Holding the bottle in the center of the sterile field or with the label facing away from the palm does not directly impact the sterility of the solution. Therefore, they are not the best actions to take when pouring the sterile solution during wound irrigation.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21 years of age to become an organ donor.
- C. Your desire to be an organ donor must be documented in writing.
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response is C: Your desire to be an organ donor must be documented in writing. This is the correct answer because in order for someone to become an organ donor, their wish to donate organs after death must be formally documented. This ensures that their wishes are legally binding and will be respected. It also helps healthcare providers and family members honor the individual's decision.
Other choices are incorrect because:
A: This response does not provide the necessary information about organ donation.
B: Age requirements for organ donation may vary by country or region, but it is not a universal rule.
D: Individuals can opt-out of being an organ donor at any time, so this statement is false.
E, F, G: No information given, so it is unclear if these choices are relevant to organ donation.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle of doing good or promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by actively seeking to alleviate the client's suffering and promoting their emotional well-being.
Rationale for why the other choices are incorrect:
A: Fidelity relates to the nurse's obligation to be faithful and keep promises made to the client, which is not directly demonstrated in this scenario.
B: Veracity is the principle of truthfulness, which is not the primary focus of the nurse's actions in this situation.
C: Autonomy refers to respecting the client's right to make their own decisions, which is not the main principle being demonstrated when the nurse is providing comfort and support.
E, F, G: These choices are not provided, but based on the context of the scenario, they are not relevant to the nurse's actions in providing comfort
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Herbal remedies
- D. Acupuncture
Correct Answer: A
Rationale: The correct answer is A: Biofeedback. Biofeedback involves monitoring and controlling bodily functions to reduce pain and stress. In the case of herpes zoster, the skin lesions can be very sensitive, making it uncomfortable for the client to participate in biofeedback sessions. Additionally, the focus required for biofeedback may be challenging for someone experiencing pain from herpes zoster.
B: Aloe is a natural remedy that can be used topically to soothe skin irritations, including herpes zoster lesions. However, it may not provide adequate pain control.
C: Herbal remedies can be used to help manage pain in herpes zoster, such as capsaicin cream. While some herbal remedies may interact with medications, there is no general contraindication for their use in herpes zoster.
D: Acupuncture is a complementary therapy that involves inserting thin needles into specific points on the body to alleviate pain. It can be effective for pain relief in herpes zoster and is not contraindicated