Nokea
A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?
- A. Remove loose sutures first
- B. Cut below the suture knot
- C. Use clean bandage scissors
- D. Lift sutures from the skin with a sterile needle
Correct Answer: B
Rationale: Cutting below the suture knot prevents external contamination and reduces infection risk.
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A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?
- A. When the client has the urge to defecate
- B. Every 2 hr while the patient is awake
- C. Immediately before meals
- D. After the client feels abdominal cramping
Correct Answer: A
Rationale: The correct answer is A: When the client has the urge to defecate. This is crucial for a successful bowel training program because it helps the client establish a regular bowel routine and strengthens the mind-body connection for recognizing the urge to defecate. Taking the client to the bathroom when they feel the urge also promotes independence and empowers the client to listen to their body's signals.
Choice B (Every 2 hr while the patient is awake) is incorrect because it does not align with the principles of bowel training, which focuses on responding to the body's natural signals. Choice C (Immediately before meals) is incorrect as the timing is not based on the client's physiological cues. Choice D (After the client feels abdominal cramping) is incorrect because waiting for abdominal cramping can lead to discomfort and is not proactive in managing bowel movements.
A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
- A. Insert an IV catheter in the opposite extremity.
- B. Discontinue the existing IV infusion.
- C. Apply warm, moist compresses to the site.
- D. Elevate the extremity.
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (Choice B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (Choice A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (Choice C) could potentially worsen the inflammation. Elevating the extremity (Choice D) may provide some relief, but it does not address the root cause. Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
- A. pH 7.31
- B. pH 7.39
- C. pH 7.48
- D. pH 7.50
Correct Answer: A
Rationale: The correct answer is A: pH 7.31. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to decreased pH. Normal pH range is 7.35-7.45. pH 7.31 indicates acidosis. Choice B is within the normal range, C and D are alkalotic, and E, F, G are not provided. pH 7.31 is the most accurate representation of respiratory acidosis in this scenario.