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The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
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The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
- A. Review the client's weight pattern over the year
- B. Ask the mother to record her diet for the last 24 hours
- C. Encourage her to talk about her view of herself
- D. Give her several pamphlets on postpartum nutrition
Correct Answer: C
Rationale: Encourage her to talk about her view of herself. To an adolescent, body image is very important, and addressing this concern first facilitates further assessment.
The nurse has completed teaching the client about his low-sodium, low-fat diet. Which menu, if selected by the client, would indicate to the nurse that the client understands his diet?
- A. Mashed potatoes, spinach, and meatloaf
- B. Swordfish with Hollandaise sauce, carrots, and rice pilaf
- C. Baked chicken, wild rice, and broccoli
- D. Roast beef with gravy, baked potato with sour cream, and creamed peas
Correct Answer: C
Rationale: Baked chicken, wild rice, and broccoli are low in sodium and fat, aligning with the diet. Meatloaf, Hollandaise, and gravy/sour cream/creamed peas are high in sodium or fat.
The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.
- A. A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.
- B. I am proud that I was able to lose 10 lb, but I'm still considered obese for my height.
- C. I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.
- D. I have struggled with daily episodes of acid reflux for years, especially at nighttime.
- E. I snack on a lot of salted foods like popcorn and peanuts.
Correct Answer: A,C,D
Rationale: Smoking cigars (A), heavy alcohol use (C), and chronic acid reflux (D) are established risk factors for esophageal cancer. Obesity (B) is a weaker risk, and salted foods (E) are not directly linked.
The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?
- A. I am tired of restricting fluids but know that I need to.
- B. I feel like I am beginning to get sick with a bad cold.
- C. I have been getting a lot of nasal pain with this spray.
- D. I have recently started to experience frequent headaches.
Correct Answer: D
Rationale: Frequent headaches (D) may indicate overmedication or hyponatremia, requiring urgent reporting. Fluid restriction (A), colds (B), and nasal pain (C) are less critical.