Nokea
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
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The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
- A. Hold the next feeding.
- B. Teach the mother CPR.
- C. Maintain a normal feeding schedule.
- D. Elevate the head of the bed.
Correct Answer: D
Rationale: infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements?
- A. Take this medication with food.
- B. Take this medication one hour before meals.
- C. Take this medication one hour after meals.
- D. Take this medication with orange juice.
Correct Answer: A
Rationale: reduces GI upset
While performing care for a 72-year-old woman, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should
- A. brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
- B. use glycerin swabs to perform mouth care every 4 hours.
- C. rinse the patient's mouth with room-temperature tap water before and after meals.
- D. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.
Correct Answer: C
Rationale: will hydrate the mucous membranes and keep mouth clean
An elderly man is admitted to a medical unit with shortness of breath and is diagnosed with an upper respiratory infection (URI). He is placed on droplet precautions. The nurse has just finished giving him his PO medications. As the nurse leaves his room, the nurse should
- A. wash hands, remove the gown and mask, and throw the trash in a container outside of the room.
- B. remove the mask, wash hands, and throw the trash in a container inside the room.
- C. wash hands, remove the mask, and throw the trash in a container inside the room.
- D. remove the gown and gloves, wash hands, remove the mask, and throw the trash in a container inside the room.
Correct Answer: C
Rationale: hands should be washed before removing mask to prevent transfer of microbes to face