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. Dry the wound bed with gauze squares.
- C. Cleanse the wound with cotton balls.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: A
Rationale: A 10-mL syringe provides adequate pressure for effective, safe wound irrigation.
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A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Prepare the client for surgery with implied consent.
- D. Postpone the procedure until the staff contacts the guardian.
Correct Answer: C
Rationale: Implied consent applies in emergencies when delay risks life, and the guardian is unavailable.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. You need to talk with your doctor about this.
- C. Why are you refusing to receive blood products?
- D. I understand that you decided not to receive blood products.
Correct Answer: D
Rationale: Acknowledging the refusal respects autonomy and builds trust, avoiding confrontation.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Wipe the inside of the inner cannula with a folded pipe cleaner.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A,B,C,D,E
Rationale: A,B,C,D,E sequence prepares solution, removes cannula, cleans it, and then cleans stoma, maintaining sterility.
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 apply a thin layer of talc powder around the stoma before placing the appliance.
- B. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- C. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- D. I will clean around the stoma with a moisturizing soap.
Correct Answer: C
Rationale: Pressing the barrier ensures adhesion, preventing leaks and maintaining skin integrity.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Complete an incident report about the breach of confidentiality.
- B. Tell the nurse that permission from the risk manager is required to view the client's record.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: C
Rationale: Reminding about access protocol directly addresses unauthorized viewing, maintaining confidentiality per HIPAA.