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A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.
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A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.
A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.
A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
- A. Dehydration
- B. Rigid abdomen
- C. Hypothermia
- D. Decreased bowel sounds
Correct Answer: A
Rationale: The correct answer is A: Dehydration. Diarrhea can lead to fluid and electrolyte loss, resulting in dehydration. Symptoms may include increased thirst, dry mouth, decreased urine output, and sunken eyes. Dehydration can be dangerous if not addressed promptly. Choices B, C, and D are unlikely findings with diarrhea. A rigid abdomen suggests a more serious condition like peritonitis, hypothermia is not a typical complication of diarrhea, and decreased bowel sounds may indicate a paralytic ileus, not commonly associated with diarrhea.
A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
- A. Crushing the medication would release all the medication at once, rather than over time
- B. Crushing the medication might cause you to have a stomachache or indigestion
- C. Crushing the medication is a good idea, and I can mix in some ice cream for you
- D. Crushing is unsafe, as it destroys the ingredients in the medication
Correct Answer: B
Rationale: The correct answer is B. Crushing enteric-coated aspirin can lead to stomachache or indigestion because the coating is designed to protect the stomach lining from irritation. By crushing it, the medication can be released too quickly, causing irritation. Choice A is incorrect because it focuses on the timing of medication release rather than the potential harm of crushing it. Choice C is incorrect as adding ice cream does not address the issue of medication safety. Choice D is incorrect as it does not provide a specific reason why crushing is unsafe.