Nokea
The nurse is performing a dressing change for a client with an infected wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.
- A. Pull glove off over the soiled dressing to encase it before disposal
- B. Save unused sterile 4x4s by taping original package shut for the next dressing change
- C. Wash hands prior to putting on gloves and after removing them
- D. Wrap soiled dressing in paper towels before disposing of it in the trash can
Correct Answer: A,C
Rationale: Encasing the dressing in a glove and washing hands before and after glove use prevent contamination. Saving sterile supplies compromises sterility, and wrapping in paper towels before regular trash disposal risks infection spread; biohazard disposal is required.
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A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: Denial, per Kübler-Ross's
Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct Answer: B
Rationale: Nursing advocacy prioritizes client self-determination, supporting autonomy in healthcare decisions. The other options address different aspects of care or legal protection. Coordinated Care
The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is
- A. The top layer of the skin is destroyed.'
- B. The skin layers are swollen and reddened.'
- C. All layers of the skin were destroyed in the burn.'
- D. Muscle, tissue and bone have been injured.'
Correct Answer: C
Rationale: All layers of the skin were destroyed in the burn.' A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.
The nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?
- A. Ask another nurse to watch the current assigned clients until the incoming nurse arrives
- B. Tape-record a report and leave a cell phone number to call if there are any questions
- C. Tell the charge nurse of the impending need to leave and that client coverage is required
- D. Write out a report about the clients for the incoming nurse prior to leaving
Correct Answer: C
Rationale: Notifying the charge nurse ensures proper client coverage and maintains continuity of care without abandoning patients. Asking another nurse assumes their availability, tape-recording lacks interaction, and a written report alone does not ensure immediate supervision.
The nurse is observing client care activities on the unit. It would require completion of an incident report if
- A. clozapine is held for a client with schizophrenia who has a decreased absolute neutrophil count
- B. escitalopram is administered to a client with major depressive disorder who received the last dose of phenelzine yesterday
- C. isosorbide mononitrate is held for a client with chronic angina who has a blood pressure of 84/52 mm Hg
- D. warfarin is administered to a client who has a mechanical heart valve and a normal INR
Correct Answer: B
Rationale: Administering escitalopram within 24 hours of phenelzine, a monoamine oxidase inhibitor, risks serotonin syndrome, a life-threatening condition, requiring an incident report. Holding clozapine for low neutrophils, holding isosorbide for low blood pressure, and giving warfarin for a normal INR are appropriate actions.