Question

A client returns to the unit following a cardiac catheterization with a femoral artery access. Which objective criteria is most important for the practical nurse (PN) to obtain immediately upon the client's return?

Answer 1

Correct Answers:

Pedal pulses.

Rationale :

🔹 After a femoral artery cardiac catheterization, monitoring distal circulation is the top priority because impaired pulses may indicate bleeding, hematoma, or arterial occlusion.

🔹 Pedal pulses reflect perfusion to the lower extremities, which is at risk from vascular complications at the insertion site.

🔹 Changes may suggest ischemia or clot formation, requiring urgent intervention.

🔹 Pupils, mobility, and respiratory rate are important but do not assess for vascular compromise at the access site.

🔹 Immediate and frequent vascular checks are the nurse’s highest priority.

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Answer 2

Correct Answers:

Complete blood count (CBC).

Rationale :

🔹 Enoxaparin (Lovenox) is a low molecular weight heparin that affects coagulation and increases risk for bleeding.

🔹 Monitoring the CBC, especially hemoglobin, hematocrit, and platelets, helps detect bleeding or heparin-induced thrombocytopenia (HIT).

🔹 BUN and creatinine are useful for kidney clearance but not the most important.

🔹 Protein, albumin, and electrolytes are not directly impacted by enoxaparin.

🔹 CBC is the priority safety lab with anticoagulants.

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Answer 3

Correct Answers:

Call the healthcare provider, clearly state the purpose of the call, and provide the details of the client's condition.

Rationale :

🔹 The nurse’s duty is client advocacy, regardless of personal stress or provider attitude.

🔹 Prompt reporting ensures timely diagnosis and treatment of a possible infection.

🔹 Avoiding the call or delegating it compromises care and delays intervention.

🔹 Using SBAR communication (Situation, Background, Assessment, Recommendation) can reduce stress and improve clarity.

🔹 Professional accountability requires direct, clear communication with the provider.

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Answer 4

Correct Answers:

Place a pulse oximeter on the infant's foot.

Rationale :

🔹 The newborn is showing respiratory distress (nasal flaring, retractions, grunting, tachypnea, dusky color).

🔹 The first step is to assess oxygenation using a pulse oximeter before implementing interventions or notifying the provider.

🔹 Oxygen saturation provides objective data to guide urgent care.

🔹 Bath delay and blood glucose are unrelated priorities.

🔹 Accurate SpO₂ determines the need for immediate oxygen therapy.

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Answer 5

Correct Answers:

Use a gloved finger to rub the suspension over the infected area.

Rationale :

🔹 For infants, oral nystatin suspension is best applied directly to the affected mucosa using a gloved finger.

🔹 This ensures medication contacts the Candida lesions effectively.

🔹 Syringes or bottles may dilute or reduce effectiveness.

🔹 Irrigation is not necessary and may be unsafe in infants.

🔹 Direct topical application provides maximum antifungal effect.

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Answer 6

Correct Answers:

Measure the client's nose-earlobe-xiphoid distance.

Rationale :

🔹 Before inserting an NG tube, the nurse must measure from nose → earlobe → xiphoid process to determine proper insertion length.

🔹 This ensures the tube reaches the stomach without being too short or too deep.

🔹 Lubrication and suction setup occur later in the procedure.

🔹 Checking bowel sounds does not determine NG tube length.

🔹 Correct measurement prevents malpositioning and complications.

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Answer 7

Correct Answers:

Clamp the nasogastric tube for 30 minutes after instilling the medication.

Rationale :

🔹 After administering medications via NG tube, it should be clamped for 30 minutes to allow absorption.

🔹 Returning to suction immediately would remove the medication, reducing effectiveness.

🔹 Leaving it open to air increases aspiration risk.

🔹 The correct action is temporary clamping before resuming suction.

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Answer 8

Correct Answers:

Respiratory obstruction.

Rationale :

🔹 In the immediate postoperative period, airway and breathing take priority.

🔹 Respiratory obstruction is life-threatening and must be addressed before dehydration, infection, or cardiac arrest risk.

🔹 Ensuring a patent airway follows the ABC principle (Airway, Breathing, Circulation).

🔹 Other risks develop later but are not immediate.

🔹 Airway compromise can rapidly cause hypoxia and death.

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Answer 9

Correct Answers:

Thick red fluid with clots in urinary tubing 12 hours postoperatively.

Rationale :

🔹 After TURP with continuous bladder irrigation (CBI), urine should be light pink and gradually clear.

🔹 Thick red urine with clots at 12 hours indicates possible hemorrhage or obstruction.

🔹 Bright red urine may be normal immediately after surgery, but not with clots after 12 hours.

🔹 Light yellow urine after 48 hours indicates healing.

🔹 Brown fluid at 24 hours may reflect old blood but is less urgent than active clots.

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Answer 10

Correct Answers:

Compare the ID bracelet with the MAR and ask the client's name.

Rationale :

🔹 The safest identification method is two identifiers: the ID bracelet and client’s verbal statement of name.

🔹 This aligns with The Joint Commission’s patient safety goals.

🔹 Solely checking the bracelet or asking family is not sufficient.

🔹 Asking the client to state orientation details is useful but does not replace ID verification.

🔹 Medication safety begins with positive patient identification.

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QLexNursing

1 :
A client returns to the unit following a cardiac catheterization with a femoral artery access. Which objective criteria is most important for the practical nurse (PN) to obtain immediately upon the client's return?

2 :
Which serum lab test is most important for the nurse to monitor when administering enoxaparin to a client?

5 :
Which approach should the PN take in administering nystatin (oral) suspension to the gums of an infant with a candida infection?

6 :
When inserting a nasogastric tube, which action should the practical nurse (PN) perform first ?

7 :
The practical nurse (PN) is administering a client's medication via a nasogastric tube. The nasogastric tube attaches intermittent suction. Which action should the PN take after administering the medication?

8 :
During the immediate postoperative period, which condition has the highest priority when planning nursing

10 :
Which is the best way to for the practical nurse (PN) to identify a client before administering medication?

QLexNursing

1 : A client returns to the unit following a cardiac catheterization with a femoral artery access. Which objective criteria is most important for the practical nurse (PN) to obtain immediately upon the client's return?

2 : Which serum lab test is most important for the nurse to monitor when administering enoxaparin to a client?

5 : Which approach should the PN take in administering nystatin (oral) suspension to the gums of an infant with a candida infection?

6 : When inserting a nasogastric tube, which action should the practical nurse (PN) perform first ?

7 : The practical nurse (PN) is administering a client's medication via a nasogastric tube. The nasogastric tube attaches intermittent suction. Which action should the PN take after administering the medication?

8 : During the immediate postoperative period, which condition has the highest priority when planning nursing

10 : Which is the best way to for the practical nurse (PN) to identify a client before administering medication?

1 :
A client returns to the unit following a cardiac catheterization with a femoral artery access. Which objective criteria is most important for the practical nurse (PN) to obtain immediately upon the client's return?

2 :
Which serum lab test is most important for the nurse to monitor when administering enoxaparin to a client?

5 :
Which approach should the PN take in administering nystatin (oral) suspension to the gums of an infant with a candida infection?

6 :
When inserting a nasogastric tube, which action should the practical nurse (PN) perform first ?

7 :
The practical nurse (PN) is administering a client's medication via a nasogastric tube. The nasogastric tube attaches intermittent suction. Which action should the PN take after administering the medication?

8 :
During the immediate postoperative period, which condition has the highest priority when planning nursing

10 :
Which is the best way to for the practical nurse (PN) to identify a client before administering medication?