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A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
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A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control. Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors. Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression. Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To determine the infusion rate, we first calculate the total volume of the solution to be infused (100 mL) over the total time (1 hr). Therefore, the infusion pump should be set to deliver 100 mL/hr (Choice C). This ensures the correct administration of potassium chloride 10 mEq IV over 1 hr. Choices A, B, and D are incorrect because they do not accurately reflect the infusion rate required for the specified dose and time frame.
A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
- A. Wound tissue firm to palpation
- B. Dry brown eschar
- C. Light yellow exudate
- D. Dark red granulation tissue
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.