Nokea
A client with a necrotizing spider bite is to perform his own dressing changes at home.
The nurse is aware that which of the following statements, if made by the client, indicates a correct understanding of aseptic technique?
- A. I need to buy sterile gloves to redress this wound.'
- B. I should wash my hands before redressing my wound.'
- C. I should keep the wound covered at all times.'
- D. I should use an over-the-counter antimicrobial ointment.'
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-indicates understanding of asepsis, whose hallmark is handwashing (3) is not possible to carry out (4) should use only the prescribed medications on the wound
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A client with a cholesterol level of $240 \mathrm{mg}$ is instructed to modify his diet. Which of the following diets provides a low-cholesterol, low-saturated fat breakfast?
- A. Oatmeal, skim milk, toast with margarine, orange juice, coffee
- B. French toast, margarine, syrup, crisp bacon, coffee
- C. Pancake, margarine, syrup, sausage, fresh fruit, tea
- D. Toasted bagel, cream cheese, poached egg, coffee
Correct Answer: A
Rationale: Oatmeal, skim milk, and margarine are low in cholesterol and saturated fat, unlike bacon, sausage, or cream cheese.
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
- A. Report any changes in hearing immediately because this is a common side effect.
- B. You should be taking vitamin B6 to prevent painful neuritis.
- C. If your big toes become painful, you must tell the physician.
- D. Your perspiration and urine may turn red-orange.
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
- A. Call the health care provider
- B. Access the use of a window in the cast
- C. Simply record the findings in the nurse's notes only
- D. Outline the spot with a pencil and note the time and date on the cast
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following statements by the client indicates a need for further teaching?
- A. I should drink plenty of water while taking this medication.
- B. I should report a rash to my doctor.
- C. I should take this medication with food.
- D. I should stop this medication if my gout attacks stop.
Correct Answer: D
Rationale: Stopping allopurinol when gout attacks stop is incorrect, as it is used long-term to prevent uric acid buildup. Options A, B, and C are correct: water prevents kidney stones, rash may indicate hypersensitivity, and food reduces GI upset.