Nokea
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over the top of blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct Answer: A
Rationale: Applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue.
You may also like to solve these questions
A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?
- A. Increased physical activity
- B. Lowered immune system function
- C. Regular health screenings
- D. Proper nutrition
Correct Answer: B
Rationale: Lowered immune system function in older adults increases susceptibility to infections.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.
A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct Answer: B
Rationale: A pulse deficit indicates ineffective cardiac contractions and the presence of cardiac dysrhythmias.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only if needed
- B. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray
- C. Keep the dressing tray on the client's bed
- D. Avoid talking during the procedure
Correct Answer: B
Rationale: If liquid comes in contact with the sterile field at any point, it is considered contaminated and unsterile, necessitating the restart of the procedure.