Nokea
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
- A. Observe careful hand-washing procedures.
- B. Clean the incisional area with an antiseptic.
- C. Use prepackaged sterile dressings to cover the incision.
- D. Place soiled dressings in a waterproof bag before disposing of them.
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.
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The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
The following scenario applies to the next 1 items
The emergency department nurse cares for a child with otitis media
Item 1 of 1
Nurses' Note
Vital Signs
Orders
1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
- A. ventrogluteal
- B. dorsogluteal
- C. Abdomen
- D. nerve damage.
- E. staining of the skin
- F. hydrocortisone
- G. EMLA (lidocaine and prilocaine)
Correct Answer: A,D,G
Rationale: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?
- A. I may have to quit driving until I get the cataracts treated.'
- B. I should spend less time outdoors in the sun and plan more activities at night.'
- C. I will need to avoid activities that raise my intraocular pressure, such as bending at the waist.'
- D. I will have to be careful since my eyes won't move together.'
Correct Answer: A
Rationale: Cataracts can impair vision, making driving unsafe until treated. Sun exposure does not directly affect cataracts, intraocular pressure is not a primary concern, and eye movement misalignment is not typical.
The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?
- A. Mild incisional pain.
- B. Clear drainage from the incision.
- C. Slight numbness in the toes.
- D. Stable vital signs.
Correct Answer: B
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.