Nokea
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. Goggles
- C. Gown
- D. Mask
Correct Answer: A
Rationale: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The sequence then proceeds with goggles, gown, and mask to minimize contamination risk.
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A nurse is caring for a client who speaks a different language than the nurse and is 5 hours postoperative. Which of the following actions should the nurse take to determine the client's level of pain?
- A. Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level.
- B. Ask an assistive personnel who speaks the same language as the client to interpret.
- C. Use a communication board to interact with the client.
- D. Use the FACES pain scale to gauge the client's level of pain.
Correct Answer: C
Rationale: Using a communication board is an effective way to assess the client's pain level and location, overcoming the language barrier. The FLACC scale is for infants/children, AP interpretation is unreliable, and the FACES scale may not be culturally understood.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 125/85 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Measure the client's BP in the other arm.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Request a prescription for an antihypertensive medication.
Correct Answer: B
Rationale: Measuring the client's BP in the other arm is the correct action to confirm the accuracy of the reading and rule out errors. A narrower cuff or faster deflation can skew results, and requesting medication is premature without verifying the elevation and assessing its cause.
A nurse is preparing to administer sucralfate 80 mg/kg/day divided into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/10 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 7 mL
Rationale: Calculate: 80 mg/kg/day × 35 kg = 2800 mg/day; 2800 mg ÷ 4 doses = 700 mg/dose; 1 g = 1000 mg, so 700 mg = 0.7 g; 1 g/10 mL = 0.7 g/X mL, X = 7 mL. Answer: 7 mL.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Tighten the abdominal muscles.
- B. Bend at the waist.
- C. Keep legs straight.
- D. Hold object away from the body.
Correct Answer: A
Rationale: Tightening the abdominal muscles supports the spine and prevents injury. Bending at the waist, keeping legs straight, or holding the object away increases back strain.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the waist.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Bearing weight on the unaffected leg is key to the three-point gait, moving crutches and the affected leg together. Crutch tips should be 15 cm from feet, at hip level, with bent arms.