Nokea
The nurse is performing perineal care for a female client. It would be appropriate for the nurse to
- A. Clean the client from the anal area to the urethral area.
- B. Vigorously dry the area with a clean towel.
- C. Ensure that the client's door is kept closed during the procedure.
- D. Use warm water and a soap containing alcohol.
Correct Answer: C
Rationale: Closing the door ensures privacy during perineal care. Cleaning backward risks infection, vigorous drying irritates, and alcohol-soap is harsh.
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The nurse is performing a home safety assessment for an older adult. Which intervention would be appropriate for the nurse to recommend to reduce the client's risk of falling?
- A. Installation of non-slip mats in the kitchen
- B. Placement of furniture in the center of rooms
- C. Remove locks from doors
- D. Painting walls with bright colors
Correct Answer: A
Rationale: Non-slip mats reduce fall risk by improving traction. Furniture placement, door locks, and wall color do not directly address falls.
The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply.
- A. I should open sterile packages away from my body.
- B. If the sterile field gets contaminated, I should dispose of everything and start over.
- C. One inch (2.5 cm) border around a sterile drape can be touched with clean fingers.
- D. I should apply sterile gloves on my non-dominant hand first.
- E. An object placed below my waist is considered contaminated.
Correct Answer: A,B,D,E
Rationale: Opening packages away, restarting after contamination, applying gloves correctly, and recognizing below-waist contamination are correct. The 1-inch border is non-sterile and should not be touched.
The right brake on your client's wheelchair is not holding as strongly as the left brake. What is the priority action?
- A. Ask the client if this happened today.
- B. Immediately remove the wheelchair from use.
- C. Try to tighten the brake with a simple tool.
- D. Call the physical therapist for another wheelchair.
Correct Answer: B
Rationale: Removing the wheelchair from use is the priority to prevent falls or injuries due to malfunction.
The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
- A. Place the client in a prone position
- B. Approach the client from the left side
- C. Instruct the client to perform deep breathing and coughing exercises
- D. Instruct client to avoid bending down
- E. Orientate the client to the environment
- F. Obtain a prescription for a stool softener
Correct Answer: B,D,E,F
Rationale: Post-scleral buckling surgery, the client’s positioning depends on the surgeon’s orders, but prone positioning is often avoided to prevent pressure on the eye. Approaching from the left side preserves the client’s intact visual field. Deep breathing and coughing may increase intraocular pressure and are typically avoided. Avoiding bending down prevents increased intraocular pressure. Orienting the client to the environment promotes safety due to potential vision changes. A stool softener prevents straining, which could increase intraocular pressure.
The nurse recognizes which of the following treatments are alternative treatments for anxiety. Select all that apply.
- A. Black cohosh
- B. Ginger
- C. St. John's wort
- D. Kava
- E. Passion flower
Correct Answer: D,E
Rationale: Kava and passion flower are used for anxiety relief. Black cohosh treats menopausal symptoms, ginger aids nausea, and St. John’s wort is for depression.