Nokea
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM.
- A. What is the most appropriate action for a saturated dressing with dark, greenish-yellow drainage two hours after T-tube removal?
- B. Remove the dressing and replace it with a more absorbent dressing.
- C. Collect a culture and sensitivity specimen of the drainage.
- D. Observe the wound for dehiscence.
- E. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile after T-tube removal. Replacing the saturated dressing with a more absorbent one keeps the site clean and dry, preventing infection. Cultures are unnecessary without infection signs, dehiscence is unlikely, and reinforcing risks infection.
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A client has a three-way Foley catheter following a transurethral resection.
The nurse would anticipate infusing irrigating solution rapidly when
- A. the urinary output is increased.
- B. bright-red drainage or clots are present.
- C. dark-brown drainage is present.
- D. the client complains of pain.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) not a reason to infuse irrigating solution rapidly (2) correct-three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtts/min when the drainage clears (3) not indication to infuse irrigating solution rapidly (4) not indication to infuse irrigating solution rapidly
A laboring woman says to the LPN/LVN, 'My baby is coming! My baby is coming!' She was last checked 15 minutes ago and was 5 cm dilated. What should the LPN/LVN do initially?
- A. Have her checked to see if she has progressed
- B. Reassure her that she cannot be that far along
- C. Reposition her to begin pushing
- D. Request medication to help her relax
Correct Answer: A
Rationale: Urgent reports of delivery sensation require immediate cervical check to confirm progression, as rapid labor can occur, ensuring timely intervention.
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at site
- C. Local tenderness
- D. Seizure activity
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.
The nurse is caring for an 80-year-old client with Parkinson’s disease.
- A. What is the most realistic and appropriate nursing goal for an 80-year-old client with Parkinson’s disease?
- B. Return the client to usual activities of daily living.
- C. Maintain optimal function within the client’s limitations.
- D. Prepare the client for a peaceful and dignified death.
- E. Arrest progression of the disease process in the client.
Correct Answer: B
Rationale: Parkinson’s disease is progressive and irreversible, so maintaining optimal function within the client’s limitations is the most realistic goal, focusing on mobility, safety, and quality of life. Returning to normal activities, preparing for death, or arresting progression are unrealistic or inappropriate.
A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended