Nokea
The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should
- A. Clean the wound with sterile saline.
- B. Pat dry the wound with gauze.
- C. Irrigate the wound with hydrogen peroxide.
- D. Don sterile gloves
Correct Answer: A
Rationale: Cleaning with sterile saline removes debris, ensuring an accurate culture. Drying, using peroxide, or sterile gloves (clean gloves suffice) are not appropriate.
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The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply.
- A. Limiting visitation to 30 minutes per day.
- B. Keeping the door to the client's room closed.
- C. Wearing a surgical mask when providing care.
- D. Placing the client in a room at the end of the hall.
- E. Cleaning common surfaces with 70% isopropyl alcohol.
Correct Answer: B,C
Rationale: Influenza requires droplet precautions, including a surgical mask within 3 feet and a closed door to reduce transmission. The other options are not standard for influenza.
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.
The nurse recognizes which of the following is considered an internal disaster?
- A. Water failure in the facility.
- B. Overcrowding in the emergency department.
- C. Mass shooting at a nearby concert.
- D. Shortage of opioid analgesia in the surgical department.
Correct Answer: A
Rationale: Water failure is an internal disaster as it originates within the facility. A mass shooting is external, while overcrowding and shortages are operational issues.
The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.