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A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?
- A. Initiate protective isolation.
- B. Allow the wound to air periodically.
- C. Clean the incision with soap and water.
- D. Perform hand hygiene prior to dressing changes.
Correct Answer: D
Rationale: The correct answer is D: Perform hand hygiene prior to dressing changes. This is important to prevent introducing harmful bacteria to the surgical wound, reducing the risk of infection. Hand hygiene is a crucial infection control measure as it helps to minimize the transfer of microorganisms. Initiating protective isolation (A) is not necessary for preventing incisional infections. Allowing the wound to air periodically (B) can actually increase the risk of contamination. Cleaning the incision with soap and water (C) may not be appropriate as it can irritate the wound and disrupt the healing process.
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A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
A nurse is assisting in interviewing a client who is being admitted from a long-term care facility. In which of the following situations should the nurse ask a closed-ended question?
- A. Determining if the client is eating a well-balanced diet
- B. Asking the client about his receptiveness to the transfer
- C. Determining how the client completes his ADLs
- D. Asking if the client took his medications this morning
- E. *
Correct Answer: D
Rationale: Closed-ended questions are useful for obtaining specific, factual information, such as whether the client took their medications.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C. Listening attentively when the client talks about the past is essential in helping the older adult cope with feelings of grief. By actively listening, the nurse validates the client's feelings and provides a supportive environment for the client to express and process their emotions. This approach shows empathy and understanding, which can help the client feel heard and respected.
Choice A is incorrect because simply stating that it is a common problem does not address the client's individual feelings and may diminish the significance of their grief. Choice B is incorrect as it suggests avoidance rather than addressing the client's emotions directly. Choice D is incorrect as comparing the client's experience to that of younger clients may not be relevant or helpful.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.