Nokea
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma bleeds lightly when touched.
- B. The stoma is draining a small amount of liquid stool.
- C. The stoma appears dark in color.
- D. The stoma protrudes slightly from the abdomen.
Correct Answer: C
Rationale: A dark stoma may indicate ischemia, necessitating immediate provider attention.
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A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Drink a glass of milk before bedtime.
Correct Answer: D
Rationale: Milk contains tryptophan, promoting serotonin and melatonin production to aid sleep.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Infection control. C: Proper site. E: Disinfection; A causes hemolysis, D reduces blood flow.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Make sure four fingers fit between the restraint and the client's body.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: A
Rationale: Applying restraints over clothing prevents skin irritation and adds comfort, reducing risks of abrasions and pressure sores.
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 preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following 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. Wipe the inside of the inner cannula with a folded pipe cleaner.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A,B,C,D,E
Rationale: A,B,C,D,E sequence prepares solution, removes cannula, cleans it, and then cleans stoma, maintaining sterility.