Nokea
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
- A. Place the patient under contact precautions
- B. Use strict aseptic technique when caring for the wound
- C. Place another dressing to reinforce the first one
- D. Elevate the patient's leg to prevent more drainage
Correct Answer: A
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.
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A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode
- B. Administer stool softeners daily as prescribed
- C. Administer antidysrhythmics PRN as prescribed
- D. Maintain the client on strict bed rest
Correct Answer: B
Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
- A. Diarrhea
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Hyperactive bowel sounds
Correct Answer: C
Rationale: In the scenario of persistent vomiting, the child is at risk of developing metabolic alkalosis due to the loss of hydrochloric acid. Vomiting leads to the loss of gastric acid, resulting in an imbalance that causes metabolic alkalosis. Metabolic acidosis is incorrect as it would occur in a child with diarrhea due to the loss of bicarbonate. While diarrhea can sometimes be associated with vomiting, in this case, the primary focus is on the effects of vomiting. Hyperactive bowel sounds are not typically associated with vomiting, making this choice less relevant to the situation described.
A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
- A. Pre-interaction
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.