Nokea
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Elevate the area and apply light pressure over the site.
- B. Apply a cold pack to the area for twenty minutes.
- C. Document the site where the medication was given.
- D. Notify the healthcare provider of the allergic response.
Correct Answer: C
Rationale: Documenting confirms normal intradermal reaction.
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A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Paper mask and gown.
- B. A sputum specimen.
- C. The nurse's stethoscope.
- D. Bed linens.
Correct Answer: A
Rationale: Contaminated mask and gown require biohazard disposal.
Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Share personal values to put the client at ease.
- D. Begin with questions that are less sensitive in nature.
Correct Answer: D
Rationale: Less sensitive questions build rapport.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Impaired bed mobility.
- B. Fluid volume deficit.
- C. Bowel incontinence.
- D. Caregiver role strain.
Correct Answer: B
Rationale: Diarrhea risks dehydration, requiring urgent fluid management.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
- A. Consult the palliative care team about the client's care.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Obtain a 'do not resuscitate' (DNR) prescription.
Correct Answer: C
Rationale: Clarifying 'heroic measures' ensures client wishes are understood.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Instruct the client to use guided imagery and slow rhythmic breathing.
- B. Place a hot water circulation device, such as an Aqua K pad, to the operative site.
- C. Tune to a television show or easy listening music to provide distraction.
- D. Provide at least 20 minutes of back massage and gentle effleurage.
Correct Answer: A
Rationale: Guided imagery promotes relaxation to manage moderate pain.