Nokea
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only if needed
- B. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray
- C. Keep the dressing tray on the client's bed
- D. Avoid talking during the procedure
Correct Answer: B
Rationale: If liquid comes in contact with the sterile field at any point, it is considered contaminated and unsterile, necessitating the restart of the procedure.
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A nurse is teaching a client about the correct use of a cane. What should the nurse include?
- A. Ensure the cane has a rubber cap
- B. Hold the cane on the stronger side
- C. Flex the elbow slightly when using the cane
- D. Use a quad cane for increased support
Correct Answer: B
Rationale: The cane should be held on the stronger side to provide support and stability while walking.
A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct Answer: A
Rationale: Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep.
A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct Answer: B
Rationale: The nurse should first reassess the client's BP to confirm the reading before taking any further action.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is reviewing the health history of an older adult who has a hip fracture. The nurse should identify what is a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for skin breakdown and pressure injuries.