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A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Remove sutures using sterile technique.
- C. Inspect the wound for signs of infection.
- D. Document the removal of sutures.
Correct Answer: B
Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.
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During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?
- A. Stringy, white tissue
- B. Translucent, red tissue
- C. Soft, yellow tissue
- D. Thick, black tissue
Correct Answer: B
Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.
The client is receiving discharge instructions for warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will have my blood tested regularly to monitor my INR levels.
- C. I will take the medication at the same time every day.
- D. I will use a soft toothbrush to prevent bleeding gums.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin need to be consistent with their vitamin K intake to maintain a balance in blood clotting. Avoiding foods high in vitamin K is essential as they can interfere with the medication's effectiveness. Choices B, C, and D are all correct statements regarding warfarin therapy. Regular blood testing to monitor INR levels ensures the medication is working effectively, taking the medication at the same time daily maintains a consistent level in the bloodstream, and using a soft toothbrush helps prevent gum bleeding due to warfarin's anticoagulant effects.
The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?
- A. Ensure that the client's circulation is checked every hour.
- B. Document the reason for the restraints every 4 hours.
- C. Provide range-of-motion exercises every 2 hours.
- D. Release the restraints every 2 hours for repositioning.
Correct Answer: D
Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?
- A. Assist the ambulating client back to the bed.
- B. Encourage the client to ambulate to resolve pneumonia.
- C. Obtain a prescription for portable oxygen while ambulating.
- D. Move the oximetry probe from the finger to the earlobe.
Correct Answer: A
Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.
When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?
- A. I can concentrate best in the morning.
- B. I feel anxious about learning the process.
- C. I have a lot of questions about insulin.
- D. I am not sure if I can manage this at home.
Correct Answer: A
Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.