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A nurse is reinforcing teaching with a client who has a new prescription for a medicated foot powder. Which of the following instructions should the nurse include?
- A. Apply the powder to wet feet.
- B. Use the powder twice a week.
- C. Apply a thick layer between the toes.
- D. Wear socks after applying the powder.
Correct Answer: D
Rationale: Wearing socks after applying medicated foot powder helps keep the medication in place and prevents spreading.
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A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
A nurse is caring for a client who has a new diagnosis of fibromyalgia. Which of the following findings should the nurse expect?
- A. Chronic pain
- B. Weight loss
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Chronic pain, often widespread, is a hallmark symptom of fibromyalgia affecting muscles and joints.
A nurse is caring for a client who has a new prescription for enoxaparin. Which of the following laboratory values should the nurse monitor?
- A. Platelet count
- B. Blood urea nitrogen
- C. Serum albumin
- D. Cholesterol
Correct Answer: A
Rationale: Enoxaparin, a low-molecular-weight heparin, can cause thrombocytopenia, so platelet count monitoring is essential.
A nurse is reinforcing teaching with a client who is scheduled for a nerve conduction study. Which of the following instructions should the nurse include?
- A. Avoid caffeine before the study.
- B. Remove all jewelry before the study.
- C. Expect sedation during the study.
- D. Fast for 8 hours before the study.
Correct Answer: B
Rationale: Removing all jewelry before a nerve conduction study prevents interference with the electrical signals measured.