Nokea
The nurse is caring for a patient one week post-surgery.Which finding should the nurse expect to see if the surgical incision is healing properly?
- A. Eschar and slough in the wound.
- B. Beety red granulation tissue.
- C. Erythema and serosanguineous drainage.
- D. A well-approximated incision.
Correct Answer: D
Rationale: A well-approximated incision means that the edges of the wound are close together and aligned properly, which is a sign that the surgical incision is healing properly.
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A postoperative client has been prescribed three different analgesics for different levels of pain.What is the most important intervention the nurse should take when administering these medications to the client?
- A. Administer each medication at the same time to ensure pain relief.
- B. Administer the medication with the highest dose first, then the others.
- C. Administer the medications as ordered based on the client's pain level.
- D. Administer the medication with the longest duration of action
Correct Answer: C
Rationale: The most important intervention the nurse should take when administering these medications to the client is to assess the client's pain level and administer the appropriate medication based on the level of pain.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
- A. Reinsert the peripheral IV catheter.
- B. Verify that the restraints can be quickly released.
- C. Assess capillary refill distal to the restraints.
- D. Replace the nasogastric tube.
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
- A. I'm sorry but your son's medical information is none of your business.
- B. The healthcare provider will share this information with you.
- C. I can only give medical information to your son because he is an adult.
- D. I will get these results back from the lab as soon as possible.
Correct Answer: C
Rationale: The best response for the nurse to provide is 'I can only give medical information to your son because he is an adult.' Since the client is 19 years old and considered an adult, the nurse must respect the client's right to privacy and confidentiality.