Nokea
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I can expect to have regular periods until I am in menopause.
- C. The best time to perform a breast self-examination is on the first day of my period.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: A
Rationale: Declining estrogen in perimenopause can cause headaches, reflecting hormonal changes.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Cleanse the wound with cotton balls.
- C. Dry the wound bed with gauze squares.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: D
Rationale: Holding the syringe 2.5 cm above provides adequate pressure for irrigation without trauma.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Check the client's range of motion every 6 hr.
- B. Make sure two fingers fit under the restraints.
- C. Secure the restraints with a square knot.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: B
Rationale: Ensuring two fingers fit under restraints prevents excessive tightness and maintains circulation.
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. (Move the steps, placing them in the order of performance.)
- A. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- B. Open each side flap of the sterile kit individually while pulling to the side.
- C. Prepare a dry work surface above the waist level.
- D. Open the outside cover of the sterile kit and remove the dust cover.
- E. Grasp the outermost flap of the sterile kit while opening away from the body.
Correct Answer: C,D,E,B,A
Rationale: C: Set up surface. D: Open cover. E: Open outermost flap. B: Open side flaps. A: Open innermost flap maintains sterility.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Postpone the procedure until the staff contacts the guardian.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: Implied consent applies in emergencies when the guardian is unavailable, allowing life-saving treatment.