Nokea
The nurse is performing a dressing change for a client with an infected wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.
- A. Pull glove off over the soiled dressing to encase it before disposal
- B. Save unused sterile 4x4s by taping original package shut for the next dressing change
- C. Wash hands prior to putting on gloves and after removing them
- D. Wrap soiled dressing in paper towels before disposing of it in the trash can
Correct Answer: A,C
Rationale: Encasing the dressing in a glove and washing hands before and after glove use prevent contamination. Saving sterile supplies compromises sterility, and wrapping in paper towels before regular trash disposal risks infection spread; biohazard disposal is required.
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Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Quality care involves meeting or exceeding standards and expectations, not merely performing at a minimal level, which is insufficient for quality. Coordinated Care
The nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?
- A. Ask another nurse to watch the current assigned clients until the incoming nurse arrives
- B. Tape-record a report and leave a cell phone number to call if there are any questions
- C. Tell the charge nurse of the impending need to leave and that client coverage is required
- D. Write out a report about the clients for the incoming nurse prior to leaving
Correct Answer: C
Rationale: Notifying the charge nurse ensures proper client coverage and maintains continuity of care without abandoning patients. Asking another nurse assumes their availability, tape-recording lacks interaction, and a written report alone does not ensure immediate supervision.
The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?
- A. I should avoid alcohol intake with this new medication.
- B. I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L).
- C. I should read the labels on all foods I eat, including those that say 'sugarless'.
- D. This medication will help me lose weight.
Correct Answer: D
Rationale: Glyburide stimulates insulin release to lower blood glucose but does not promote weight loss; it may cause weight gain. Avoiding alcohol, reporting hypoglycemia, and checking food labels are correct actions, indicating understanding.
A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m² (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?
- A. Child's pattern of daily physical activity
- B. Family's eating habits
- C. Family's financial resources for purchasing healthy foods
- D. Family's readiness for change
Correct Answer: D
Rationale: The family's readiness for change is critical, as it determines their willingness to adopt and sustain lifestyle changes necessary for weight loss. While activity, eating habits, and finances are important, motivation drives success.
Four clients have requested medication for pain. The licensed practical nurse should give priority to medicating:
- A. The client with a fractured femur
- B. The client with a closed head injury
- C. The client with a laminectomy
- D. The client with a posterior myocardial infarction
Correct Answer: D
Rationale: Pain from a myocardial infarction indicates ongoing ischemia, requiring immediate attention to reduce cardiac demand. Fractured femur, laminectomy, and head injury pain, while serious, are less immediately life-threatening.