Nokea
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client has poorly fitting dentures.
- B. The client verbalizes regret about never marrying.
- C. The client is sedentary throughout most of the day.
- D. The client has no living family.
Correct Answer: C
Rationale: Sedentary behavior heightens risks like DVT and cardiovascular issues, making it the priority.
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A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. There has been too much complaining about these changes.
- B. So you are upset about all of the recent changes on the unit?
- C. Why don't you just file a formal complaint with Human Resources?
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Acknowledging feelings fosters discussion and support, addressing the AP’s concerns.
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 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 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.