Nokea
A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?
- A. "Keep a nightlight on in the bathroom"
- B. "Set room temperature to 68 degrees Fahrenheit"
- C. "Place throw rugs over electrical cords"
- D. "Use chairs without armrests"
Correct Answer: A
Rationale: The correct answer is A: 'Keep a nightlight on in the bathroom.' This safety measure is crucial for older adults to prevent falls by enhancing visibility during nighttime bathroom visits. Choice B is incorrect because setting the room temperature to 68 degrees Fahrenheit may not be universally suitable for all older adults, as individual preferences vary. Choice C is incorrect as placing throw rugs over electrical cords poses a tripping hazard rather than enhancing safety. Choice D is incorrect as using chairs without armrests may not provide adequate support and stability for older adults, increasing the risk of falls.
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While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?
- A. Crackles
- B. Rhonchi
- C. Friction rub
- D. Normal breath sounds
Correct Answer: D
Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.
When providing a bath, in which order will the nurse clean the body, beginning with the first area?
- A. Face
- B. Eyes
- C. Perineum
- D. Back and buttocks
Correct Answer: B
Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.
What is the most important action for preventing infection in a client with a central venous catheter?
- A. Changing the catheter dressing every 72 hours.
- B. Flushing the catheter with heparin solution daily.
- C. Ensuring the catheter is clamped when not in use.
- D. Maintaining sterile technique when handling the catheter.
Correct Answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.
What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?
- A. Encourage the client to use an incentive spirometer regularly.
- B. Assist the client in ambulating as soon as possible.
- C. Position the client in high Fowler's position.
- D. Encourage the client to cough and deep breathe regularly.
Correct Answer: A
Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.
The healthcare provider is caring for a client with a wound infection. Which type of dressing is most appropriate to use to promote healing by secondary intention?
- A. Dry gauze dressing
- B. Wet-to-dry dressing
- C. Transparent film dressing
- D. Hydrocolloid dressing
Correct Answer: D
Rationale: Hydrocolloid dressings are ideal for promoting healing by secondary intention in wound infections. These dressings create a moist environment that supports autolytic debridement and facilitates the healing process. Dry gauze dressings (Option A) may lead to adherence, causing trauma upon removal and disrupting the wound bed. Wet-to-dry dressings (Option B) are primarily used for mechanical debridement and can be painful during dressing changes. Transparent film dressings (Option C) are more suitable for superficial wounds with minimal exudate and are not typically used for wound infections requiring healing by secondary intention.