Nokea
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique
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The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
- A. Administer the medication as ordered.
- B. Hold the medication and notify the physician.
- C. Administer half the prescribed dose.
- D. Recheck the pulse in 30 minutes and then administer the medication.
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Mild sedation.
- B. Dry mouth.
- C. Dizziness upon standing.
- D. Insomnia.
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious lorazepam side effect. Options A, B, and D are common.