Nokea
The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
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The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
- A. Advances the walker 6-10 inches.
- B. Has their elbow flexed 15-30 degrees.
- C. Tilts the walker forward to help stand up from a chair.
- D. Advances the walker and then the affected leg.
Correct Answer: C
Rationale: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. Performs hand hygiene and applies clean gloves
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: A 15-degree HOB increases aspiration risk; it should be 30-45 degrees. Towels go in regular laundry, not biohazard. Other actions are correct.