Nokea
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Open the outside cover of the sterile kit and remove the dust cover
- B. Grasp the outermost flap of the sterile kit while opening away from the body.
- C. Prepare a dry work surface above the waist level
- D. Open the innermost lower flap of the sterile kit while standing away from the sterile field
- E. Open each side flap of the sterile kit individually while pulling to the side
Correct Answer: C, A, B, D, E
Rationale: Sequence maintains sterility: prepare surface, open kit, unfold flaps systematically.
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A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Assign different nurses to provide care for clients each day.
- B. Restrict the number of visitors for clients.
- C. Offer the clients many choices regarding care.
- D. Turn on loud music in client care areas.
Correct Answer: B
Rationale: Restricting visitors reduces noise and stress in an acute care setting.
Nurses' Notes
Diagnostic Results
Day 1:
1000:
A peripherally inserted central catheter (PICC) is inserted into left arm. Dressing dry and intact. Bilateral breath sounds clear and present throughout.
1200:
Parenteral nutrition started through PICC line infusing at 75 mL/hr.
Day 3:
0800:
Client is lethargic and reports thirst and frequent urination. Bilateral breath sounds clear and present throughout.
A nurse is reviewing the medical record of a client who has a paralytic ileus.
Select words from the choices below to fill in each blank in the following sentence:
The findings in the client's medical record indicate----and----.
- A. Dehydration
- B. Pneumothorax
- C. Hyperglycemia
- D. Infection
- E. Electrolyte Imbalance
- F. Hypoglycemia
Correct Answer: A, C
Rationale: A: Thirst and urination suggest dehydration. C: Lethargy and polyuria indicate hyperglycemia from parenteral nutrition.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
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 1/2 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 barrier ensures a secure seal, preventing leaks.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. There has been too much complaining about these changes.
- B. Please, try to wait a little longer. Things will get better soon.
- C. So, you are upset about all of the recent changes on the unit?
- D. Why don't you just file a formal complaint with Human Resources?
Correct Answer: C
Rationale: Reflecting the AP's feelings encourages open communication.