Nokea
The nurse is caring for a client with a pressure ulcer.
- A. Which intervention is most effective for promoting healing of a stage III pressure ulcer?
- B. Apply a hydrocolloid dressing.
- C. Cleanse the wound with hydrogen peroxide.
- D. Reposition the client every 4 hours.
- E. Administer oral antibiotics.
Correct Answer: A
Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.
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The nurse is caring for clients on a medical/surgical unit and determines that several situations need to be addressed.
- A. Which situation should the nurse attend to first?
- B. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
- C. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
- D. The physician calls the unit to ask the nurse to obtain a client’s laTest serum electrolyte results from the lab.
- E. The husband of a client reports to the nurse that his wife’s nose began bleeding after she returned from radiation therapy.
Correct Answer: D
Rationale: A nosebleed post-radiation therapy is the least stable situation, as it may indicate a serious complication like thrombocytopenia or tissue damage, requiring immediate assessment. Legal threats, staff issues, and lab result requests are less urgent than a potentially life-threatening condition.
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
- A. A client with laparoscopic cholecystectomy
- B. A client with viral pneumonia
- C. A client with suspected ectopic pregnancy
- D. A client with intermittent chest pain
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift?
- A. Resting after receiving IM pain medication.
- B. No bowel sounds present.
- C. IV infusing at 100 cc/h.
- D. Breath sounds decreased in both lower lobes.
Correct Answer: D
Rationale: Decreased breath sounds suggest atelectasis or pneumonia, serious post-cholecystectomy complications due to reduced ventilation from pain. Options A, B, and C are routine: resting is expected, absent bowel sounds are normal post-surgery, and IV rate is standard.
Prior to suctioning a tracheotomy, the nurse should:
- A. Suction the oropharynx.
- B. Administer oxygen.
- C. Change the inner cannula.
- D. Raise the head of the bed.
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.