Nokea
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Tell the client that it is safe to touch her ostomy.
- B. Request that someone from the client's family participate in the care.
- C. Ask the client to explain her feelings.
- D. Explain why her participation is important.
Correct Answer: C
Rationale: Exploring feelings helps address emotional barriers to self-care.
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A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Wipe the inside of the inner cannula with a folded pipe cleaner.
Correct Answer: A,B,C,E,D
Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. I understand that you decided not to receive blood products.
- C. You need to talk with your doctor about this.
- D. Why are you refusing to receive blood products?
Correct Answer: B
Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.
A nurse is assisting with developing a plan of care for a client.
Exhibit 1
Nurses' Notes
2 days ago:
Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.
Today, 0900:
Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.
Complete the following sentence by using the lists of options. The nurse understands that which of the following dressing should be added to the plan of care
- A. hydrocolloid
- B. dry gauze
- C. hydrogel
- D. alginate
- E. transparent
Correct Answer: A
Rationale: Hydrocolloid dressings promote healing in full-thickness wounds with minimal exudate.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Document the refusal in the client's medical record.
- D. Inform the client of the potential consequences of their refusal
Correct Answer: D
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
- A. Cotton-tipped applicator
- B. Tongue depressor
- C. Adhesive tape
- D. Syringe
Correct Answer: D
Rationale: A syringe is used for irrigation to clean a stage 4 pressure injury with deep tissue involvement.