Nokea
The nurse is changing a wet to dry dressing. Which action is appropriate?
- A. Pouring sterile solution directly into the wound
- B. Removing the old dressings with sterile gloves
- C. Opening the sterile dressings wearing sterile gloves
- D. Packing the wound wearing sterile gloves
Correct Answer: D
Rationale: Packing the wound with sterile gloves maintains sterility, ensuring proper wet-to-dry dressing application for debridement.
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Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
- A. Direct confrontation
- B. Reality orientation
- C. Projective identification
- D. Active listening
Correct Answer: D
Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.
A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse?
- A. How is your spouse's new job going?'
- B. I've noticed that you seem frustrated lately.'
- C. It's normal to be angry when you can't work anymore.'
- D. We have a support group that can help you adjust to rehab.'
Correct Answer: B
Rationale: Acknowledging observed behavior (B) opens a therapeutic conversation and validates the client's feelings. Asking about the spouse's job (A), assuming anger (C), or suggesting a support group (D) may not address the client's current emotional state.
The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children?
- A. Attending a child's memorial service
- B. Avoiding expressing personal feelings of grief or loss directly with the family
- C. Ending personal contact with the deceased's family members after they leave the hospital
- D. Increasing length of daily exercise routines
Correct Answer: D
Rationale: Increasing exercise (D) is a healthy coping strategy to manage stress. Attending memorials (A), avoiding grief expression (B), or ending contact (C) may not promote long-term emotional resilience.
The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?
- A. Bronchial breath sounds
- B. Increased tactile fremitus
- C. Low-pitched wheezing (rhonchi)
- D. Pleural friction rub
Correct Answer: D
Rationale: Pleural friction rub (D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B, C) are less specific or urgent.
The nurse is providing teaching to the parents of a 1-year-old who was just prescribed a 10-day course of amoxicillin for acute otitis media. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Give your child over-the-counter decongestants to help speed up recovery'
- B. If your child develops loose stools, please discontinue the antibiotic'
- C. Return to the clinic if your child does not improve within 48-72 hours.'
- D. Stop administering the amoxicillin if your child is feeling better in 5-7 days.'
- E. Your child may need a hearing screening after the ear infection has resolved.'
Correct Answer: C, E
Rationale: Returning if no improvement (C) and hearing screening (E) are appropriate. Decongestants (A) are not recommended, loose stools (B) do not warrant stopping, and stopping early (D) risks resistance.