Nokea
A student nurse is assigned to change a patient's dressing. The soiled bandage is saturated with bright red blood. How should the student nurse dispose of the bandage?
- A. in the hallway sharps container
- B. in a labeled or color-coded biohazard bag
- C. in the trash, but it must be double bagged
- D. in the trash can in the patient's room
Correct Answer: B
Rationale: Blood-saturated bandages are biohazardous and must be disposed of in a labeled biohazard bag to prevent infection transmission.
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The nurse is preparing the client for surgery. The pre-op medication includes atropine sulfate 0.4 mg, meperidine (Demerol HCl) 50 mg, and promethazine hydrochloride (Phenergan) 25 mg IM. Which action should the nurse do first?
- A. make sure the surgical permit is signed
- B. ask the client to go to the bathroom
- C. explain the purpose of the medication to the client
- D. ask family members to exit the room
Correct Answer: A
Rationale: Ensuring the surgical permit is signed is the priority to confirm informed consent before administering preoperative medications.
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching?
- A. The child should not play on his rocking horse.
- B. Applying warm compresses will decrease pain.
- C. Diapering should be avoided for 1-2 weeks.
- D. The child will need a special diet to promote healing.
Correct Answer: A
Rationale: Avoiding straddling activities like rocking horses prevents strain on the surgical site post-hypospadias repair.
The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication?
- A. I will take the medication each morning after breakfast.
- B. I will check my heart rate before taking the medication.
- C. I will report visual disturbances to my doctor.
- D. I will stop the medication if I develop gastric upset.
Correct Answer: C
Rationale: Reporting visual disturbances is important, as they may indicate levothyroxine overdose or other complications, reflecting proper understanding.
The primary cause of anemia in a client with chronic renal failure is:
- A. Poor iron absorption
- B. Destruction of red blood cells
- C. Lack of intrinsic factor
- D. Insufficient erythropoietin
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production by the kidneys, leading to decreased red blood cell production and anemia.
The nurse has just received a report from the previous shift. Which of the following clients should the nurse visit first?
- A. A 50-year-old COPD client with a PCO2 of 50
- B. A 24-year-old admitted after an MVA complaining of shortness of breath
- C. A client with cancer requesting pain medication
- D. A 1-day post-operative cholecystectomy with a temperature of 100°F
Correct Answer: B
Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. The other clients' conditions are less acute.