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A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
- A. Have the client remove the existing dressing while the nurse prepares sterile supplies
- B. Wear clean gloves for removal and application of a new dressing
- C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
- D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing
Correct Answer: C
Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.
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The nurse is reinforcing teaching with a client in the postpartum period who is breastfeeding and has breast engorgement. Which of the following information should the nurse include?
- A. Apply ice packs to your breasts for 15 to 20 minutes before breastfeeding
- B. Allow your baby to nurse for at least 10 to 15 minutes on each breast
- C. Temporarily decrease the frequency of your breastfeeding
- D. Avoid taking NSAIDs for discomfort while breastfeeding
Correct Answer: B
Rationale: Nursing for 10-15 minutes per breast relieves engorgement by emptying milk ducts. Ice packs are used after, not before, feeding; decreasing frequency worsens engorgement; and NSAIDs are safe for breastfeeding.
The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
The nurse checks the lab values of a newly admitted client. RBC: 4.0 million/mm³, WBC: 1500/mm³, Platelets: 40,000/mm³. What nursing actions are indicated because of these lab values?
- A. Keep the client on bed rest and protective isolation.
- B. Plan for protective isolation and do not give injections.
- C. Keep the client on bed rest and avoid trauma.
- D. There are no special nursing actions indicated.
Correct Answer: B
Rationale: Low WBC (neutropenia) requires protective isolation, and low platelets (thrombocytopenia) contraindicate injections to prevent bleeding and infection.
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
The nurse is evaluating how a client who has a halo brace is reacting to this change in his body image. Which statement by the client indicates a need for additional support in adjusting to the brace?
- A. I shall avoid going out in public since I may bump into people.'
- B. I don't mind that people look at me.'
- C. I told my grandchildren that this looks like a space helmet.'
- D. I like to sleep in the reclining chair that we have.'
Correct Answer: A
Rationale: Avoiding public interaction suggests poor adjustment to the halo brace, indicating a need for support to address body image concerns.