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The nurse is caring for a client with a venous leg ulcer. Which of the following interventions should be included in the plan of care?
- A. Apply compression bandages.
- B. Keep the leg in a dependent position.
- C. Clean the ulcer with alcohol-based solution.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Compression bandages promote venous return and healing in venous leg ulcers.
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The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.
Which of the following is a risk factor for toxic shock syndrome (TSS)?
- A. Changing tampons every 3 hours.
- B. Avoiding use of deodorized tampons.
- C. Alternating tampons with sanitary pads.
- D. Using only tampons at night.
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.
A client is prescribed lansoprazole for the chronic management of Zollinger-Ellison syndrome. The nurse determines that the client best understands this disorder and the medication regimen when the client reports taking which product for pain?
- A. Naprosyn
- B. Ibuprofen
- C. Acetaminophen
- D. Acetylsalicylic acid
Correct Answer: C
Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should take acetaminophen for pain relief. The client should not take medications that irritate the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (naprosyn and ibuprofen).
Which of the following is an example of beliefs of traditional Chinese medicine found in a small amount of the treatment?
- A. Health is described as harmony between family members.
- B. Illness is caused by an imbalance of the yin and yang.
- C. Exercise to the point of overexertion can improve health.
- D. Illness is caused by a change in eating habits.
Correct Answer: B
Rationale: Traditional Chinese medicine attributes illness to an imbalance of yin and yang.
Which of the following is not considered one of the 'Ten Rights of Medication Administration'?
- A. The 'right' verification
- B. The 'right' to refuse
- C. The 'right' documentation
- D. The 'right' client education
Correct Answer: A
Rationale: The Ten Rights of Medication Administration include right patient, drug, dose, route, time, documentation, reason, response, refusal, and education. 'Right verification' is not a standard right.