Nokea
The nurse is caring for a client with a stage II sacral ulcer. Which nursing intervention would be most effective in promoting healing?
- A. a heat lamp positioned 12 inches from the skin for 10 minutes twice a day
- B. antibiotic therapy as ordered
- C. increasing the client's nutritional intake of protein and calories
- D. wet to dry dressings once every shift
Correct Answer: C
Rationale: Increased protein and calorie intake supports tissue repair and healing for a stage II ulcer, more than heat lamps, antibiotics (unless infection is present), or wet-to-dry dressings.
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A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A. Place the client in a sitting position.
- B. Administer acetaminophen (Tylenol).
- C. Pinch the soft lower part of the nose.
- D. Apply ice packs to the forehead.
Correct Answer: C
Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?
- A. file an incident report and document the finding in the client's medical record
- B. document the finding in the client's medical record only
- C. report the incident to the nursing supervisor
- D. file an incident report but do not document the finding in the client's medical record
Correct Answer: A
Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.
All of the following statements regarding scarlet fever are true EXCEPT
- A. rheumatic fever is a possible complication of scarlet fever.
- B. scarlet fever can be treated with antibiotics.
- C. a vaccine is available to protect against scarlet fever.
- D. scarlet fever is caused by an erythrogenic toxin.
Correct Answer: C
Rationale: No vaccine exists for scarlet fever, which is caused by Streptococcus pyogenes’ erythrogenic toxin and treated with antibiotics. Rheumatic fever is a complication.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- A. Have a Protime done monthly
- B. Eat more fruits and vegetables
- C. Drink more liquids
- D. Avoid crowds
Correct Answer: A
Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.