Nokea
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
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During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test.
- A. Instruct the client to drink a 75 gm glucose solution.
- B. Tell the client to eat a high carbohydrate diet for three days prior to the exam.
- C. Instruct the client to remain NPO after midnight.
- D. Obtain a fasting blood glucose level.
- E. Obtain a two-hour post-prandial glucose level.
Correct Answer: B,C,D,A,E
Rationale: When placing in chronological order, the nurse should: tell the client to increase the amount of carbohydrates for three days prior to the exam; instruct the client to remain NPO after midnight the day of the exam; obtain a fasting blood glucose level; instruct the client to drink a 75 gm glucose solution; and obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logical sequence. Think about the natural order of the question.
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
- A. Periorbital edema, absent light reflex and translucent tympanic membrane
- B. Irritability, rhinorrhea, and bulging tympanic membrane
- C. Diarrhea, fever, and reddened tympanic membrane
- D. Vomiting, pulling at ears and pearly white tympanic membrane
Correct Answer: B
Rationale: Irritability, rhinorrhea, and bulging tympanic membrane. These findings are characteristic of otitis media, indicating infection and inflammation of the middle ear.
A woman in a residence facility is having difficulty sleeping at night. Which action by the nurse is most appropriate initially?
- A. Ask the physician for a sleeping medication
- B. Offer the woman a back rub and warm milk
- C. Suggest to the woman that she take a walk around the unit
- D. Offer the woman a cup of hot tea
Correct Answer: B
Rationale: A back rub and warm milk promote relaxation non-pharmacologically, addressing insomnia safely. Medication, walking, or tea (caffeine) are less appropriate.
A young woman has routine blood work done at her prenatal appointment. The results indicate that she has a hemoglobin level of 10 g/dL. The nurse explains to her that this result is:
- A. high.
- B. insignificant.
- C. low.
- D. normal.
Correct Answer: C
Rationale: A hemoglobin of 10 g/dL is low (normal in pregnancy: 11-12 g/dL), indicating possible anemia, requiring further evaluation.