Nokea
During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
- A. Face
- B. Feet
- C. Chest
- D. Arms
Correct Answer: A
Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.
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A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
- A. Suction the client's airway
- B. Administer a bronchodilator
- C. Increase the humidity in the client's room
- D. Assist the client to an upright position
Correct Answer: D
Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.
Following surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason?
- A. To reduce strain on the incision
- B. To promote drainage of the wound
- C. To provide stimulation for the client
- D. To reduce edema at the operative site
Correct Answer: D
Rationale: The high-Fowler position is preferred after neck surgery to reduce edema at the operative site. Elevating the head of the bed promotes venous return and drainage, aiding in decreasing swelling and fluid accumulation, which helps reduce edema at the operative site. Choice A is incorrect as the main purpose is not solely about reducing strain on the incision. Choice B is incorrect because while drainage may occur, it is not the primary reason for maintaining the high-Fowler position. Choice C is incorrect as providing stimulation is not the primary rationale for positioning the client in high-Fowler.
When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
- A. Press gently on the tragus of the client's ear.
- B. Pull the ear lobe up and back.
- C. Insert the medication deeply into the ear canal.
- D. Massage the ear gently after administering the medication.
Correct Answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client's ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.
When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?
- A. Hydrocolloid
- B. Gauze
- C. Transparent film
- D. Alginate
Correct Answer: A
Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.
The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?
- A. Hypertension
- B. Bradycardia
- C. Hypoglycemia
- D. Weight gain
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.