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The nurse is performing a dressing change on a client with a stage 3 sacral wound. Once the old dressing is removed, the nurse would perform which step next?
- A. wash hands
- B. chart the findings
- C. assess the wound
- D. prepare the sterile field
Correct Answer: C
Rationale: Assessing the wound after removing the dressing guides subsequent care and sterile field preparation.
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A client has been admitted to the oncology unit and has a large amount of cash, several credit cards, and several pieces of expensive-looking gold jewelry in her possession. Which action by the nurse is most appropriate?
- A. tell the client to hide everything in her purse or a bag and put it in the closet
- B. offer to take her belongings to the charge nurse's office where they can be locked up
- C. suggest that the client put her valuables in a sock and place it in the bottom of the bedside table under some clothing
- D. inform the client of the hospital policy regarding valuables and suggest that she give them to a trusted family member or to security for safekeeping
Correct Answer: D
Rationale: Informing the client of hospital policy and suggesting secure storage with family or security follows protocol and ensures safety of valuables. Options A, B, and C do not align with standard hospital procedures for securing valuables.
The nurse is caring for an elderly client with osteoporosis who has fractured her mid-shaft clavicle. Which nursing intervention would be included on the plan of care?
- A. immobilize the affected shoulder with a sling
- B. encourage weight-bearing exercise
- C. increase fluids to 1,500 cc/day
- D. prepare for surgical repair
Correct Answer: A
Rationale: A sling immobilizes the clavicle to promote healing and reduce pain. Weight-bearing exercise is inappropriate, and surgery is rarely needed for mid-shaft fractures.
The nurse manager has approval to add one LPN to the RNs in the medical-surgical unit. Which nursing actions does the nurse manager expect the LPN to be able to perform according to most state board of nursing practice acts? Select all that apply.
- A. draw blood from a PICC line
- B. access a port with a Huber needle
- C. perform hemodynamic monitoring
- D. transcribe written physician orders
- E. perform finger-prick blood glucose testing
Correct Answer: A,D,E
Rationale: LPNs can typically draw blood from PICC lines, transcribe orders, and perform glucose testing. Accessing ports and hemodynamic monitoring are usually RN responsibilities.
A client is being treated for pulmonary hypertension. The nurse knows that the involvement of nursing, pharmacy, cardiology, physical therapy, and nutritional services is an example of which of the following approaches?
- A. continuity of care
- B. case management
- C. quality improvement
- D. interdisciplinary
Correct Answer: D
Rationale: An interdisciplinary approach involves multiple specialties collaborating for comprehensive client care.