Nokea
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Blister integrity (A), pain relief with ibuprofen (C), and cool water (D) are correct. Ice can worsen damage, and open air isn't recommended initially.
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A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure.
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps.
Correct Answer: B
Rationale: Fasting except for water 12 hours prior ensures a clear colon for the colonoscopy. Enemas aren't standard, clear liquids are typically 24 hours, and polyp removal occurs during the procedure.
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A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Clamp the catheter tubing distal to the sampling port for 15 min.
- B. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Empty the urine into a sterile container labeled with the client identifiers.
- E. Document in the client's electronic medical record that the specimen was sent to the laboratory
- F. Wash hands before starting.
- G. Check the client's ID band.
Correct Answer:
Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Hydrogen peroxide
- C. Bleach
- D. Chlorhexidine
Correct Answer: C
Rationale: AIDS, caused by HIV, requires strict infection control due to bloodborne transmission risk. Option C, bleach (typically a 1:10 dilution with water), is correct CDC guidelines recommend it for disinfecting HIV-contaminated surfaces, as it effectively inactivates the virus by denaturing proteins. Option A, isopropyl alcohol, disinfects but isn't the standard for blood spills; it evaporates quickly, potentially leaving viable pathogens. Option B, hydrogen peroxide, oxidizes but lacks evidence as a primary bloodborne pathogen disinfectant compared to bleach. Option D, chlorhexidine, excels for skin antisepsis, not environmental surfaces or blood cleanup. Bleach's broad-spectrum efficacy, affordability, and alignment with universal precautions make it the gold standard. Teaching this ensures the new nurse protects themselves and others, adhering to OSHA and hospital protocols, while reinforcing the importance of proper dilution (e.g., 1 part bleach to 9 parts water) for safety and effectiveness.
A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase vitamin C intake by drinking orange juice.
- B. I will eat six small meals each day.
- C. I will lie down for 30 minutes after each meal.
- D. I will sleep flat on my back at night.
Correct Answer: B
Rationale: Six small meals reduce stomach pressure and reflux in GERD. Orange juice can worsen reflux, lying down post-meal increases it, and sleeping flat doesn't help.
A nurse in a provider's office is assisting in the care of a client. Complete the following sentence: The first action the nurse should take is to reinforce education about...
- A. nutritional supplements followed by collecting data about nutritional intake.
- B. increasing fluid intake followed by monitoring respiratory rate.
- C. checking blood pressure followed by administering oxygen.
- D. assessing fatigue followed by ordering a chest X-ray.
Correct Answer: A
Rationale: The client's generalized weakness, fatigue, shortness of breath, and pale mucous membranes (Exhibit 1) with a vegan diet suggest anemia, likely iron deficiency. Reinforcing education about nutritional supplements (e.g., iron, Bâ‚â‚‚) addresses potential deficiencies vegans risk low iron and Bâ‚â‚‚ without fortified foods while collecting intake data identifies dietary gaps, guiding tailored therapy. Increasing fluids and monitoring respiration might help hydration or respiratory distress, but anemia is the primary issue, not fluid status. Checking blood pressure (132/60 to 102/50 mm Hg) shows orthostasis, a symptom, not the cause oxygen isn't indicated with 94% saturation. Assessing fatigue is ongoing, but a chest X-ray targets lungs, not anemia. Education and data collection tackle the root nutritional cause, aligning with holistic care and prevention, making it the nurse's first action.