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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The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects?
- A. Decreased blood pressure and growth delays
- B. Heart palpitations and weight gain
- C. Loss of appetite and restlessness
- D. Trouble sleeping and a dry cough
Correct Answer: C
Rationale: Methylphenidate commonly causes loss of appetite and restlessness . Hypotension , palpitations/weight gain , and cough are less typical.
A client with psychotic depression is receiving Haldol (haloperidol). Which of the following side effects is associated with antipsychotic medications such as haloperidol?
- A. Akathesia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathesia , a movement disorder, is a common side effect of haloperidol. Cataracts , diaphoresis , and polyuria are not typically associated.
The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
- A. You need to regain your strength before attempting such exertion.'
- B. When you can climb 2 flights of stairs without problems, it is generally safe.'
- C. Have a glass of wine to relax you, then you can try to have sex.'
- D. If you can maintain an active walking program, you will have less risk.'
Correct Answer: B
Rationale: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .