Nokea
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct Answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
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The client is being instructed on how to collect a clean catch urine specimen. Which sequence is appropriate for teaching?
- A. Void a little, clean the meatus, then collect specimen
- B. Clean the meatus, begin voiding, then catch urine stream
- C. Clean the meatus, then urinate into container
- D. Void continuously and catch some of the urine
Correct Answer: B
Rationale: The correct sequence for obtaining a clean catch urine specimen involves first cleaning the meatus to prevent contamination, then initiating voiding to catch the midstream urine. This method ensures that the sample is as uncontaminated as possible, making choice B the correct sequence. Option A is incorrect as cleaning the meatus should be done before voiding. Option C is incorrect as it does not involve catching a midstream urine sample. Option D is incorrect as it suggests catching urine throughout the entire voiding process, which may lead to contamination.
A healthcare professional is preparing to administer gentamicin 2 mg/kg via IV bolus to a client who weighs 220 lb. How many mg should the healthcare professional administer?
- A. 200 mg
- B. 100 mg
- C. 160 mg
- D. 180 mg
Correct Answer: C
Rationale: To calculate the dosage correctly, the weight in pounds must first be converted to kilograms. 220 lb / 2.2 = 100 kg. Then, multiply the weight in kg by the dosage of 2 mg/kg: 2 mg/kg 100 kg = 200 mg. Therefore, the correct dosage to administer is 200 mg, which is closest to option A. Option C (160 mg) is incorrect because it does not match the calculated dosage. Options B (100 mg) and D (180 mg) are also incorrect as they do not align with the correct calculation.
A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:
- A. Administer cardiac compressions
- B. Attach the AED pads to the client
- C. Check for a pulse
- D. Perform rescue breaths
Correct Answer: A
Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.
When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?
- A. Apply intermittent suction when withdrawing the catheter.
- B. Apply continuous suction during insertion of the catheter.
- C. Apply suction only during insertion of the catheter.
- D. Insert the catheter while the client is exhaling.
Correct Answer: A
Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.
A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
- A. "I'm having mild pain."
- B. "The pain is like a dull ache in my stomach."
- C. "I notice that the pain gets worse after I eat."
- D. "The pain makes me feel nauseous."
Correct Answer: B
Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.