Nokea
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120 mg/dl.
- B. History of myocardial infarction.
- C. Long term steroid usage.
- D. Diet high in carbohydrates.
Correct Answer: C
Rationale: Steroids impair wound healing by affecting collagen formation and immune response.
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A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
- A. Increase the wall suction.
- B. Strip the chest tube.
- C. Clamp the chest tube.
- D. Reposition the client.
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?
- A. Give written pre and post-tests.
- B. Ask questions during practice.
- C. Allow another diabetic to assist.
- D. Observe a return demonstration.
Correct Answer: D
Rationale: Return demonstration ensures the client can correctly perform the technique under supervision.
Until doctor's orders are received, the most appropriate position for Mr. Jones, admitted with retinal detachment, is lying
- A. flat on his back
- B. on his left side
- C. on his right side
- D. on his abdomen
Correct Answer: B
Rationale: Lying on the affected side (left side) helps reduce movement of the detached retina, minimizing further damage until definitive treatment can be administered.
When assigning staff to patients who are receiving chemotherapy, what is the major consideration about chemotherapeutic drugs?
- A. During preparation,drugs may be absorbed through the skin or inhaled.
- B. Many chemotherapeutics are vesicants.
- C. Chemotherapeutics are frequently given through central venous access devices.
- D. Oral and venous routes are the most common.
Correct Answer: A
Rationale: Safety precautions during drug preparation are paramount due to the potential for hazardous exposure to healthcare workers.
Which patient needs attention first?
- A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
- B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed
- C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed
- D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown
Correct Answer: D
Rationale: Hot, dry skin and altered mental status suggest heat stroke, a medical emergency requiring immediate cooling measures.