Nokea
A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.
- A. prevents blood clots from forming
- B. reduces post-operative swelling
- C. minimizes pain and discomfort
- D. prevents exposure to air
Correct Answer: B,C
Rationale: The figure-eight technique reduces swelling (B) by promoting venous return and minimizes pain (C) by stabilizing the limb. It does not prevent clots (A) or air exposure (D).
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The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
- A. re-cap the needle and discard it in the nearest puncture-resistant container
- B. break the needle and discard it in the nearest puncture-resistant container
- C. discard the needle in a puncture-resistant container in the central medication area
- D. discard the needle in a puncture-resistant container in the client's room
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.
A 68-year-old client states he decided not to take the herpes zoster (shingles) immunization because his friend had the immunization and still developed shingles. Which of the following information should the nurse include when discussing this issue with the client? Select all that apply.
- A. Shingles rarely occurs after immunization.
- B. The immunization decreases the severity of infection.
- C. The immunization decreases the likelihood of postherpetic syndrome.
- D. The immunization cuts the chance of developing shingles in half.
- E. The client should never take advice from friends.
Correct Answer: B,C,D
Rationale: The shingles vaccine reduces severity (B), postherpetic syndrome risk (C), and shingles incidence by about 50% (D). It doesn't eliminate risk (A), and dismissing friends' advice (E) is inappropriate.
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
- A. Holding the infant
- B. Offering a pacifier
- C. Providing a mobile
- D. Offering sterile water
Correct Answer: B
Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.
The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
- A. Assisting the LPN with opening sterile packages and peroxide
- B. Telling the LPN that clean gloves are allowed
- C. Telling the LPN that the registered nurse should perform pin care
- D. Asking the LPN to clean the weights and pulleys with peroxide
Correct Answer: A
Rationale: Sterile technique is appropriate for pin care; assisting maintains the sterile field.