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A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
- A. Cover the area with saline-soaked sterile dressings
- B. Apply an abdominal binder snugly around the abdomen
- C. Use sterile gloves to apply gentle pressure to the exposed tissues
- D. Position the client supine with hips & knees bent
- E. Offer the client a warm beverage, such as herbal tea
Correct Answer: A, D
Rationale: Correct Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (Choice A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (Choice D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (Choice B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (Choice C) can introduce contamination and should be avoided.
- Offering a warm beverage (Choice E) is irrelevant and does not address the urgent need to manage the wound.
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A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.
- A. Install bath rails & grab bars in bathrooms
- B. Wear a helmet while skiing
- C. Install a carbon monoxide detector
- D. Secure firearms in a safe location
- E. Remove throw rugs from the home
Correct Answer: B, C, D
Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (D) is essential to prevent accidents. Installing bath rails (A) and removing throw rugs (E) are more relevant to older adults to prevent falls.
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24hr postop to use an incentive spirometer
- B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
- C. Providing nasopharyngeal suctioning for a client who has pneumonia
- D. Replacing the cartridge and tubing on a PCA pump
Correct Answer: D
Rationale: The LPN should question assignment D (replacing the cartridge and tubing on a PCA pump) because this task involves medication administration and intravenous therapy, which are typically outside the LPN's scope of practice. LPNs are not trained to handle complex medication delivery systems like PCA pumps, as this requires specialized knowledge and skills that are within the RN's scope of practice. It is crucial for patient safety that tasks are assigned to healthcare providers based on their education, training, and scope of practice to prevent errors and ensure quality care. Assignments A, B, and C are within the LPN's scope of practice and can be safely performed without questioning.