Nokea
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.
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The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
The physician orders palifermin (Kepivance) 60 mcg/kg to be administered daily. The client weighs 35 kg. The medication is supplied 5 mg/mL. How many mL would you administer?
- A. 0.42 mL
- B. 30 mL
- C. 36.5 mL
- D. 33.6 mL
Correct Answer: A
Rationale: Dose: 60 mcg/kg × 35 kg = 2100 mcg = 2.1 mg. 2.1 mg ÷ 5 mg/mL = 0.42 mL. Other options are incorrect calculations.
For which of the following conditions might blood be drawn for uric acid level?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels, which are measured to confirm diagnosis and monitor treatment. The other conditions do not typically involve uric acid testing. Reduction of Risk Potential
A client asks the nurse about her beta-blockers medication effect to her angina.
What would be the nurse's response?
- A. Decrease cardiac output.
- B. Increase cardiac output.
- C. Decrease cardiac contractility.
- D. Increase cardiac contractility.
Correct Answer: C
Rationale: Beta-blockers decrease heart rate and cardiac contractility, reducing myocardial oxygen demand and relieving angina.
Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation