Nokea
The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel?
- A. Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client
- B. Please measure the Hemovac drainage at 2:00 PM and let me know how much there was.
- C. Please record the amount of Hemovac drainage on the intake and output record at the end of the shift
- D. Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught.
Correct Answer: A
Rationale: Changing a sterile dressing is a nursing task requiring sterile technique, inappropriate for unlicensed personnel. Measuring, recording, and compressing the Hemovac are within their scope.
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The nurse is reinforcing education to a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply.
- A. Breastfeeding the infant
- B. Cosleeping with the infant in the parent's bed
- C. Giving the infant a pacifier at bedtime
- D. Maintaining a smoke-free environment
- E. Placing the infant to sleep in a side-lying position
Correct Answer: A,C,D
Rationale: Breastfeeding, pacifier use, and a smoke-free environment reduce SIDS risk. Cosleeping and side-lying positions increase risk.
The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? Select all that apply.
- A. Commercial fruit juice
- B. Flavored club soda
- C. Fresh vegetable juice
- D. Sports beverages
- E. Unsweetened tea
Correct Answer: B,C,E
Rationale: Flavored club soda, fresh vegetable juice, and unsweetened tea are low-calorie, healthier alternatives to cola. Fruit juice and sports drinks are high in sugar.
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.