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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The nurse is talking with a client with obesity who has a new prescription for a lipase inhibitor. Which of the following statements by the client would require follow-up?
- A. I will take this medication in the morning on an empty stomach.
- B. I should consume a diet that is low in fat while taking this medication.
- C. I may experience oily stools and flatulence while taking this medication.
- D. I will take fat-soluble vitamins at least 2 hours before or after taking this medication.
Correct Answer: A
Rationale: Lipase inhibitors like orlistat should be taken with or within an hour of meals containing fat, not on an empty stomach, to effectively block fat absorption. The other statements are correct: low-fat diet minimizes side effects, oily stools and flatulence are common, and vitamins should be timed to avoid malabsorption.
Narrow therapeutic index medications:
- A. are drug formulations with limited pharmacokinetic variability.
- B. have limited value and require no monitoring of blood levels.
- C. have less than a twofold difference in minimum toxic levels and minimum effective concentration in the blood.
- D. have limited potency and side effects.
Correct Answer: C
Rationale: Narrow therapeutic index drugs have a small margin between effective and toxic doses, requiring close monitoring. The other descriptions are inaccurate or irrelevant. Pharmacological Therapies
The nurse is collecting data from an 18-month-old client. The nurse should suggest referral for a developmental screening test if the client
- A. does not notice when others are upset
- B. eats food using the fingers
- C. follows 1-step commands without gestures
- D. has a vocabulary of 5 words
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of 10-20 words. A vocabulary of only 5 words indicates a potential speech delay, warranting developmental screening. Noticing others' emotions develops later, finger-eating is normal, and following 1-step commands is age-appropriate.
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?
- A. Check the urethral catheter and drainage tubing
- B. Irrigate the catheter with 30 mL sterile normal saline
- C. Notify the registered nurse
- D. Remove and reinsert the next larger size catheter
Correct Answer: A
Rationale: Checking the catheter and tubing first ensures there are no kinks, blockages, or improper placements causing the leak, which is a non-invasive and logical initial step. Irrigation or removal requires further assessment, and notifying the RN is premature without initial troubleshooting.
A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate’s vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?
- A. Call the health care provider immediately
- B. Document the finding
- C. Place the neonate in a knee-chest position
- D. Provide oxygen to the neonate
Correct Answer: B
Rationale: Documenting the murmur is appropriate as genetic screening and an echocardiogram are already scheduled, indicating the provider is aware. Calling the provider is unnecessary, knee-chest position is for specific heart defects, and oxygen is not indicated without respiratory distress.