Nokea
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Cleanse the wound with cotton balls.
- B. Use a 10-mL syringe filled with cleansing solution.
- C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- D. Dry the wound bed with gauze squares.
Correct Answer: C
Rationale: This technique ensures effective irrigation without damaging tissue.
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A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm above prevents contamination and ensures proper delivery.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma protrudes slightly from the abdomen.
- B. The stoma bleeds lightly when touched.
- C. The stoma appears dark in color.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: C
Rationale: A dark stoma suggests necrosis or ischemia, requiring urgent provider notification.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place a pillow between the client's legs prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the client's arms above her head prior to logrolling.
- D. Place the bed in the lowest position before logrolling the client.
Correct Answer: A
Rationale: A pillow between legs maintains spinal alignment during logrolling post-laminectomy.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. I can name my sibling as my designee in my durable power of attorney for health care.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: B
Rationale: Naming a designee is a key component of a durable power of attorney.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Ask the client to state their room number.
- B. Have the client state their phone number.
- C. Review the client's photograph in the medical record.
- D. Request an assistive personnel to identify the client.
Correct Answer: C
Rationale: A photograph in the record is a reliable identifier for a client with dementia.