Nokea
The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
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While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. I want to protect my child from any falls.'
- B. I will set limits on exploring the house.'
- C. I understand our child's need to use those new skills.'
- D. I intend to keep control over our child's behavior.'
Correct Answer: C
Rationale: I understand our child's need to use those new skills.' Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.