Nokea
The nurse is applying a prescribed cold compress to the client's sprained ankle and recognizes that it should be applied for a maximum of
- A. 20 minutes.
- B. 10 minutes.
- C. 30 minutes.
- D. 15 minutes.
Correct Answer: A
Rationale: Cold compresses should be applied for 20 minutes to prevent tissue damage while reducing swelling. Shorter or longer durations are less effective or risky.
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Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?
- A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer.
- B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing.
- C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin.
- D. The registered nurse saturates the old dressing with sterile saline before removing it.
Correct Answer: C
Rationale: Packing wet gauze into the ulcer without overlapping onto the skin ensures effective debridement without irritating healthy tissue. Other options are incorrect techniques.
While starting a peripheral vascular access device (VAD) on a client, the nurse suffers a needlestick injury. Which action should the nurse take?
- A. Ask the client if they have the hepatitis A virus.
- B. Wash the affected extremity with soap and water.
- C. Document the incident in the client's medical record.
- D. Discontinue the vascular access device.
Correct Answer: B
Rationale: Washing with soap and water is the initial action to reduce infection risk after a needlestick.
The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.