Nokea
A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?
- A. Simple face mask
- B. Nasal prongs
- C. Non-rebreather mask
- D. Nasal cannula
Correct Answer: C
Rationale: A non-rebreather mask delivers up to 90-100% oxygen, ideal for raising saturation.
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A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Gown
- C. Goggles
- D. Mask
Correct Answer: A
Rationale: Removing gloves first prevents hand contamination when removing other PPE.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. Unnecessary sterile items are placed on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- D. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle, breaching sterility.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.
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. You need to talk with your doctor about this.
- C. Why are you refusing to receive blood products?
- D. I understand that you decided not to receive blood products.
Correct Answer: D
Rationale: Acknowledging the refusal respects autonomy and builds trust, avoiding confrontation.