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A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.
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A nurse is caring for an older adult client who has confusion and weakness. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the client's plan of care?
- A. Restrict the client's fluid intake.
- B. Monitor the client's intake and output.
- C. Weigh the client daily.
- D. Instruct the client to sit on the side of the bed for a few minutes before standing.
- E. Check the client's orientation to person, place, and time regularly.
Correct Answer: B,C,E
Rationale: The lab values suggest dehydration, so monitoring fluid balance and orientation is essential.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.
A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh-Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?
- A. Leavened bread
- B. Eggs
- C. Milk
- D. Caffeinated coffee
Correct Answer: D
Rationale: The correct answer is D: Caffeinated coffee. Seventh-Day Adventists typically avoid caffeine due to health beliefs. Coffee contains caffeine, which is considered a stimulant and is restricted. Leavened bread (A) is not specifically restricted. Eggs (B) and milk (C) are generally accepted. In summary, the other choices are incorrect because they are not specifically restricted by the Seventh-Day Adventist church.
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
- A. Unbroken skin with un-blancheable erythema
- B. Full-thickness tissue loss extending to underlying support structures
- C. A shallow, ruptured or intact skin blister without slough
- D. A deep crater without visible bone, tendon, or muscle
Correct Answer: D
Rationale: Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but without exposed bone or muscle.