Nokea
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.
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A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the skin barrier for 30 seconds ensures adhesion, preventing leakage.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Age
- D. Room number
Correct Answer: A
Rationale: A photograph, combined with other identifiers like name and birthdate, ensures positive patient identification.