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A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?
- A. Shave the hair at the insertion site.
- B. Cleanse the site with povidone-iodine.
- C. Wear sterile gloves when changing the dressing.
- D. Change the IV site every 48 to 72 hours.
Correct Answer: D
Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.
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A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?
- A. Weight gain
- B. Mouth sores
- C. Hyperpigmentation
- D. Increased saliva production
Correct Answer: B
Rationale: The correct answer is B: Mouth sores. Mouth sores are a common side effect of radiation therapy, especially when the treatment is focused on the head or neck area. Weight gain is not typically associated with radiation therapy; instead, clients may experience weight loss due to side effects like nausea and loss of appetite. Hyperpigmentation is not a common finding related to radiation therapy. Increased saliva production is not a typical side effect of radiation therapy; instead, clients may experience dry mouth.
A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Preoccupation with somatic disturbances
- D. Poor problem-solving ability
Correct Answer: B
Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.
How should pain be assessed in a non-verbal patient?
- A. Observe facial expressions
- B. Use the Wong-Baker faces scale
- C. Assess heart rate
- D. Ask the patient to rate their pain
Correct Answer: A
Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.
A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct Answer: B
Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.
What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?
- A. Apply hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Elevate the affected area
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.