Nokea
The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
- A. Assisting the LPN with opening sterile packages and peroxide
- B. Telling the LPN that clean gloves are allowed
- C. Telling the LPN that the registered nurse should perform pin care
- D. Asking the LPN to clean the weights and pulleys with peroxide
Correct Answer: A
Rationale: Sterile technique is appropriate for pin care; assisting maintains the sterile field.
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The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration
- B. The client will require frequent dressing changes
- C. The straps provide support for drains that are inserted into the incision
- D. No sutures or clips are used to secure the incision
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.
A client who was prescribed increasing dosages of baclofen to relieve muscle spasms should have taken 80 mg daily in 4 divided doses but misunderstood and took 80 mg four times a day, resulting in an overdose and pronounced CNS depression. Which of the following treatments does the nurse anticipate?
- A. Administration of naloxone.
- B. Administration of atropine.
- C. Supportive care only.
- D. Administration of flumazenil.
Correct Answer: C
Rationale: Baclofen overdose causes CNS depression, treated with supportive care (C) like ventilation and monitoring. Naloxone (A), atropine (B), and flumazenil (D) are not antidotes for baclofen.
A 54-year-old female is brought into the ED by her spouse. The client's spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
- A. calcium 7.2 mg/dL
- B. alkaline phosphatase 120 IU/L
- C. sodium 143 mEq/L
- D. creatinine 0.8 mg/dL
Correct Answer: A
Rationale: Hypocalcemia (calcium 7.2 mg/dL, normal 8.5–10.2) can cause muscle stiffness and anxiety, requiring immediate notification. Other results are normal.
A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
- A. fettuccine alfredo
- B. fried chicken
- C. grilled cheese sandwich with bacon
- D. natural peanut butter and banana sandwich on whole wheat bread
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.