Nokea
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- A. Change the dressing four times per day.
- B. Apply tincture of benzoin prior to removing the dressing.
- C. Use sterile gloves when removing the old dressing.
- D. Clean from the incision to the surrounding skin.
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
You may also like to solve these questions
A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
- A. Hold the dropper 3 cm (1.2 in) away from the client's eye.
- B. Ask the client to close their eyes tightly after instilling each medication.
- C. Massage the client's eyelids for 2-3 seconds after instillation.
- D. Wait 5 min between the administration of each medication.
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (B) or massaging the eyelids (C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using restraints, which of the following actions must the nurse take first?
- A. Obtain a prescription for restraints from the provider.
- B. Explain the procedure to the client and their family.
- C. Attempt less restrictive alternatives.
- D. Document the indications for using wrist restraints.
Correct Answer: C
Rationale: Correct Answer: C - Attempt less restrictive alternatives.
Rationale: Before resorting to using restraints, the nurse must first try less restrictive measures to ensure the safety and well-being of the client. This includes interventions such as redirecting the client's behavior, providing distractions, or addressing the underlying cause of the behavior. By attempting less restrictive alternatives, the nurse can promote the client's autonomy and prevent the potential negative effects of using restraints.
Summary:
A: Obtaining a prescription for restraints is important, but it should not be the first step.
B: Explaining the procedure to the client and their family is important but does not address the immediate need for less restrictive alternatives.
D: Documenting the indications for using wrist restraints is necessary but does not address the need to explore other options first.
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
- A. While removing medication from the container
- B. Before selecting the medication container
- C. When documenting the medication administration
- D. When providing client education about the medication
- E. At the client's bedside before administering the medication
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors. Choice C is incorrect because documentation should occur after administration. Choice D is incorrect as medication reconciliation is not part of client education.