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A client is postoperative after surgery to repair a fractured hip and has a history of atrial fibrillation. What action by the nurse is most important to prevent wound infections?
- A. Performing hand hygiene before client contact
- B. Changing the surgical dressing daily
- C. Monitoring the client's daily white blood cell count
- D. Administering prophylactic antibiotics
Correct Answer: A
Rationale: Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique, but hand hygiene is the most critical step. Assessing vital signs and white blood cell count will not prevent infection.
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The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
- A. Cholesterol: 126 mg/dL
- B. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
- C. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
- D. Triglycerides: 198 mg/dL
Correct Answer: D
Rationale: Triglycerides in men should be below 160 mg/dL. The other values are within acceptable ranges for adult males.
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
- A. Assess the client's neurological status
- B. Notify the Rapid Response Team
- C. Prepare to administer vitamin K
- D. Turn down the infusion rate
Correct Answer: B
Rationale: Clients on fibrinolytic therapy are at high risk of bleeding. Sudden neurologic signs may indicate a hemorrhagic stroke. The nurse should first call the Rapid Response Team based on the client's manifestations, then perform a thorough neurological examination.
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client states the drug is dangerous. What action by the nurse is best?
- A. Assess the reason behind the client's fear
- B. Remind the client about laboratory monitoring
- C. Tell the client drugs are safer today than before
- D. Warn the client about consequences of noncompliance
Correct Answer: A
Rationale: The first step is to assess the reason behind the client's fear, which may be related to a past experience. Addressing the specific concern is critical for effective teaching and compliance. The other options do not address the client's fear directly.
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African-American churches
- B. Asian-American groceries
- C. High school sports camps
- D. Women's health clinics
Correct Answer: A
Rationale: Providing services at African-American churches has the potential to reach this priority population, as African-Americans are at higher risk for hypertension. While hypertension education is important for all groups, this is the priority population for this intervention.
A student nurse asks what essential hypertension is. What response by the registered nurse is best?
- A. It is caused by another disease
- B. It means it must be treated immediately
- C. It has no specific cause
- D. It refers to severe and life-threatening hypertension
Correct Answer: C
Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension caused by another disease is secondary hypertension. Severe, life-threatening hypertension is malignant hypertension.