Nokea
The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
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The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to
- A. Notify the primary care provider immediately
- B. Suggest in-patient psychiatric care
- C. Respect the client's confidential disclosure
- D. Phone the family to warn them of the risk
Correct Answer: A
Rationale: Notify the primary care provider immediately. The client’s suicidal intent and plan require immediate intervention by the healthcare team.
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
- A. sedation as needed to prevent exhaustion
- B. antibiotic therapy for 10 to 14 days
- C. humidified air and increased oral fluids
- D. antihistamines to decrease allergic response
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
The nurse is caring for a client who had a transurethral resection of the prostate yesterday.
- A. What is the most concerning symptom in a client one day post-transurethral resection of the prostate?
- B. Urine output of 150 cc over 8 hours.
- C. Bladder spasms and urgency.
- D. Bright red urine with small clots.
- E. Burning on urination.
Correct Answer: A
Rationale: A urine output of 150 cc over 8 hours is critically low, indicating possible obstruction, bleeding, or renal impairment, requiring immediate intervention. Bladder spasms, bright red urine with clots, and burning are expected post-procedure but should be monitored.