Nokea
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.
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A woman who has been hospitalized for several days says she is having trouble getting to sleep. What is the best initial nursing intervention?
- A. Offer her a back rub.
- B. Ask her what she is worrying about.
- C. Give the ordered PRN sedative.
- D. Notify the physician.
Correct Answer: A
Rationale: A back rub promotes relaxation non-pharmacologically, addressing insomnia safely. Asking about worries, giving sedatives, or notifying the physician are less immediate.
The LPN on a medical unit observes a coworker taking diazepam ordered for a client. What should the nurse do initially?
- A. Immediately call the supervisor
- B. Confront the nurse
- C. Observe the nurse for unsafe behavior
- D. Administer that nurse's medications for the rest of the shift
Correct Answer: C
Rationale: Observing for unsafe behavior assesses immediate risk to patients, allowing appropriate reporting if impairment is confirmed.
An adult admitted for surgery also is diagnosed with obsessive-compulsive disorder. The client spends most of her time in the bathroom washing her hands. The client is scheduled for surgery at 8:00 A.M. and is to be premedicated at 7:00 A.M. Which nursing action will be most appropriate?
- A. Inform the client at 6:30 A.M. that she will soon be medicated and have to stay in bed after that.
- B. When medicating the client, explain to her that she will not be able to get up after receiving the medication.
- C. After medicating the client, place a wash basin and wash cloth at the bedside for her use.
- D. After medicating the client, assist her in washing her hands at the bedside.
Correct Answer: C
Rationale: Providing a wash basin accommodates her OCD hand-washing ritual, reducing anxiety post-medication while ensuring she remains in bed.
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
- A. To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
- B. To cover the bony prominence and areas where there is skin breakdown
- C. The client knows what type of clothing to wear when weighed
- D. To reduce the tendency of the client to hide objects under his or her clothing
Correct Answer: D
Rationale: To reduce the tendency of the client to hide objects under his or her clothing. Clients may conceal weights to falsely indicate weight gain.
The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol?
- A. Food poisoning
- B. Influenza
- C. Myocardial infarction
- D. Stroke
Correct Answer: C
Rationale: Symptoms like nausea, sweating, dizziness, and fatigue in a 70-year-old with diabetes suggest myocardial infarction, requiring immediate cardiac protocol initiation.