Nokea
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
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The nurse is assisting at a disaster shelter setup following a devastating earthquake. What is the most common problem the nurse is likely to see in those who come to the shelter?
- A. Thirst
- B. Traumatic injuries
- C. Stress
- D. Exacerbation of medical problems
Correct Answer: C
Rationale: Stress is the most common issue post-disaster due to trauma and displacement, affecting most survivors. Thirst, injuries, or medical exacerbations are less universal.
The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
- A. Massage legs frequently
- B. Frequent turning
- C. Moisten skin with lotions
- D. Apply moist heat to reddened areas
Correct Answer: B
Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.
The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.
- A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
- B. Increase your consumption of iron-rich foods like meat and dried fruit
- C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
- D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
- E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation
Correct Answer: A,B,D,E
Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.
The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?
- A. Tell the parents to bring the child to the clinic for further evaluation
- B. Refer the school officials to printed materials about this viral illness
- C. Inform the teacher that the child is receiving antibiotics for the rash
- D. Explain that this rash is not contagious and does not require isolation
Correct Answer: D
Rationale: Explain that this rash is not contagious and does not require isolation. Fifth Disease is not contagious once the rash appears, except in specific cases.