Nokea
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. Droplet precautions require that I wear a gown and gloves when providing client care.
- B. Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.
- C. Soiled dressings should be placed in a biohazard trash receptacle.
- D. For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.
Correct Answer: C
Rationale: Soiled dressings in biohazard receptacles prevent infection spread, showing understanding.
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The client is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy.
A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
- A. Massage the affected extremity every 4 hr.
- B. Initiate bed rest.
- C. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- D. Administer aspirin for pain.
Correct Answer: B
Rationale: Bed rest prevents dislodging the clot while on anticoagulants.
The client is visibly agitated and talking loudly in a group therapy session.
A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?
- A. Place the client in seclusion.
- B. Assist the client with understanding their needs.
- C. Ask the client to identify what made them upset.
- D. Administer lorazepam IM.
Correct Answer: C
Rationale: Identifying the trigger de-escalates agitation before further intervention.
A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Place the client in Sims' position for catheter insertion.
- B. Verify the amount of TPN solution the client is receiving every 4 hr.
- C. Use clean technique when changing the catheter dressing.
- D. Prepare the client for a chest x-ray to verify catheter placement.
Correct Answer: D
Rationale: A chest x-ray confirms correct catheter placement for TPN administration.
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will wipe away yellow crusts that form around the incision.
- B. I will make sure that my baby's diaper is applied snugly.
- C. I will apply pressure with gauze if I see bleeding.
- D. I will apply antibiotic ointment to my baby's penis.
Correct Answer: C
Rationale: Applying pressure with gauze controls bleeding, a key aspect of Plastibell circumcision care.
A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.