Nokea
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
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A client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
A nurse is caring for a client who has a respiratory infection. When the client asks how the position the nurse put him in can help, the nurse should explain that lying on his left side in Trendelenburg position helps mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Postural drainage uses gravity to mobilize mucus from different lung segments, aiding in secretion clearance.
A nurse is reinforcing teaching with a newly licensed nurse about respecting a client's personal space. The nurse should include in the teaching that which of the following actions require client consent? (Select all that apply.)
- A. Removing the client's dentures
- B. Checking capillary refill of the client's finger
- C. Palpating for pedal edema
- D. Taking a radial pulse
- E. Observing a mole on the client's shoulder
Correct Answer: A, C
Rationale: Actions that involve physical touch or intrusion into personal space, such as removing dentures or palpating edema, require consent.