Nokea
The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.
- A. Administer pain medication 30 minutes before the procedure
- B. Apply skin protectant to intact skin surrounding the wound
- C. Cut the foam dressing to the shape and size of the wound
- D. Ensure that the prescribed negative-pressure setting is applied
- E. Verify that the occlusive film dressing is free of air leaks
Correct Answer: A,B,C,D,E
Rationale: All actions are correct: pain management , skin protection , proper foam sizing , correct pressure , and leak-free dressing ensure effective therapy.
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A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
- A. Promote healing and strengthen the immune system
- B. Provide a well balanced nutritional intake
- C. Stimulate increased peristalsis absorption
- D. Spare protein catabolism to meet metabolic needs
Correct Answer: D
Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.
The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
Which of the following tasks can the nurse assign to an unlicensed assistive personnel (UAP)?
- A. assisting a client with ambulating to the bathroom for the first time following surgery
- B. expiated client with dementia who has a serum glucose level of 70 mg/dL (3.9 mmol/L)
- C. explaining why incentive spirometer use is important to a client with postoperative pneumonia
- D. taking vital signs every 15 minutes on a client who was just transferred from the postanesthesia recovery unit
Correct Answer: D
Rationale: Taking vital signs is within UAP scope. First-time ambulation , hypoglycemia , and teaching require nursing judgment.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .
Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Client admitted with WBC count of 28,000 mm3 (28.0 x 109/L) and dies from sepsis
- B. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine
- C. Client refuses pneumonia vaccination and contracts pneumonia
- D. Nurse did not report client's new hemoglobin result of 6.0 g/dL (60 g/L) to oncoming nurse
- E. Provider was not notified of client's positive blood culture results
Correct Answer: B,D,E
Rationale: Medication error , failure to report hemoglobin , and failure to notify about blood culture are reportable adverse events. Sepsis death and vaccine refusal are not necessarily preventable errors.