Nokea
A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?
- A. Irrigate the wound with normal saline.
- B. Apply a wet-to-dry gauze dressing.
- C. Use a cotton ball to cleanse the wound.
- D. Administer an analgesic after the dressing change.
Correct Answer: A
Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.
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A client is constipated and asks the nurse for advice. What should the nurse recommend?
- A. Administer a laxative to relieve discomfort
- B. Increase dietary fiber to promote bowel movements
- C. Advise the client to rest until symptoms resolve
- D. Encourage bed rest to allow bowel function to return
Correct Answer: B
Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.
A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
- A. You may breastfeed unless your nipples are cracked or bleeding.
- B. You must use a breast pump to provide breast milk.
- C. You must use a nipple shield when breastfeeding.
- D. You may breastfeed after your baby develops antibodies.
Correct Answer: A
Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.
What is the correct intervention for a patient experiencing anaphylaxis?
- A. Administer epinephrine
- B. Provide oxygen
- C. Monitor airway
- D. All of the above
Correct Answer: D
Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.
A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system
- B. Use alcohol-based hand sanitizer when leaving the client's room
- C. Clean contaminated surfaces in the client's room with a phenol solution
- D. Have family members wear a gown and gloves when visiting
Correct Answer: D
Rationale: The correct answer is D because having family members wear a gown and gloves when visiting a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will position the car seat in the front seat
- B. I will secure the car seat in the car by using the seatbelt
- C. I will use a rear-facing car seat
- D. I will install the car seat facing forward
Correct Answer: C
Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.