Vocational Nursing

Question 1/10

What should a nurse do first when caring for a client in the emergency department who may be confused due to medications?

Right Answer

When a client is confused, obtaining vital signs is the first step to assess their physiological status. Changes in blood pressure, oxygen saturation, or temperature could indicate an underlying cause of confusion, such as hypoxia or infection. Administering medication without assessment may worsen the condition, and checking for a pulse deficit is not the immediate priority. Once vital signs are obtained, further evaluations can be made to determine the best course of action.

Question 2/10

When washing hands, what action should a nurse take to ensure proper hygiene?

Right Answer

Turning off the faucet with a clean paper towel prevents recontamination of clean hands. Using a shared towel can spread bacteria, and shaking hands to dry them does not effectively remove moisture, which can harbor pathogens. Hand sanitizer is useful when soap and water are not available, but proper handwashing with soap is more effective in removing certain pathogens. Following proper hand hygiene reduces healthcare-associated infections.

Question 3/10

What finding indicates hypomagnesemia in a client with an NG tube set to low intermittent suction?

Right Answer

A positive Chvostek’s or Trousseau’s sign indicates hypomagnesemia, which is common in clients with prolonged nasogastric suction due to loss of electrolytes. Hypomagnesemia can cause neuromuscular excitability, leading to these signs. Recognizing this helps the nurse take appropriate action, such as electrolyte replacement. Monitoring electrolyte imbalances is essential for preventing complications.

Question 4/10

What should a nurse document about a client with swollen lower legs showing 6 mm edema?

Right Answer

A 6 mm indentation indicates **pitting edema**, which occurs when pressure applied to the skin leaves a visible depression. The severity of pitting edema is graded on a scale from 1+ to 4+, with 6 mm typically classified as **3+ pitting edema**. Non-pitting edema does not leave an indentation and is associated with conditions like lymphedema. Accurate documentation ensures appropriate treatment and monitoring.

Question 5/10

How should a nurse prevent health infections for clients in a care facility?

Right Answer

Hand hygiene is the most effective way to prevent healthcare-associated infections. Washing hands after glove removal, using hand sanitizer when needed, and disinfecting medical equipment like stethoscopes reduce the risk of pathogen transmission. Simply wearing gloves at all times does not replace hand hygiene. Regular cleaning protocols help maintain a safe environment for patients and healthcare workers.

Question 6/10

What action should a nurse take when checking a client for a pulse deficit after detecting an irregular heart rate?

Right Answer

A pulse deficit is the difference between the apical and radial pulse, which may indicate atrial fibrillation or cardiac dysfunction. To assess this, one nurse counts the apical pulse while another counts the radial pulse simultaneously. A significant difference suggests that not all heartbeats are effectively reaching the peripheral circulation. This assessment helps determine the need for further cardiac evaluation or intervention.

Question 7/10

Which laboratory result indicates fluid volume excess in a female client with heart failure?

Right Answer

low BUN level (below 10 mg/dL)** suggests fluid volume excess, as dilution occurs due to increased intravascular fluid. In contrast, high BUN levels may indicate dehydration or kidney dysfunction. Heart failure often leads to fluid retention, making this an important marker for assessing volume status. Monitoring BUN and other indicators like sodium levels helps guide fluid management.

Question 8/10

What complementary therapy should a nurse recommend for a client with chronic pain to concentrate on a pleasurable experience?

Right Answer

**Guided imagery** is a mind-body technique that encourages clients to focus on calming or pleasurable thoughts to reduce pain perception. It can help decrease stress, promote relaxation, and improve pain tolerance. While acupuncture, physical therapy, and massage therapy are beneficial, guided imagery specifically targets mental focus to redirect pain awareness. This technique is especially useful for chronic pain management.

Question 9/10

What action should a nurse include in the plan of care for a client with a new prescription for a wrist restraint?

Right Answer

Restraints should be removed at regular intervals to assess skin integrity, circulation, and the need for continued use. Applying them too tightly can cause skin breakdown, impaired circulation, and nerve damage. Padding bony prominences is also important, but frequent removal is necessary to prevent complications. Using restraints appropriately balances patient safety with maintaining their dignity and comfort.

Question 10/10

How should a nurse convert the weight of a preschooler from pounds to kilograms if the child weighs 30 lbs?

Right Answer

To convert pounds to kilograms, divide the weight in pounds by 2.2. \[30 \div 2.2 = 13.6 \text{ kg}\] This calculation is crucial for accurate medication dosing and treatment planning in pediatric patients. Ensuring proper weight conversion helps prevent medication errors and ensures safe, effective care.