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A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- A. Change the dressing four times per day.
- B. Apply tincture of benzoin prior to removing the dressing.
- C. Use sterile gloves when removing the old dressing.
- D. Clean from the incision to the surrounding skin.
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
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A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
- A. The client turns their head against resistance.
- B. The client's tongue is in a midline position.
- C. The client's pupils constrict in response to light.
- D. The client has a symmetrical smile.
Correct Answer: D
Rationale: The correct answer is D: The client has a symmetrical smile. Cranial nerve VII, the facial nerve, controls facial expression including smiling. When assessing this nerve, the nurse would expect the client to have a symmetrical smile indicating intact function. This is because cranial nerve VII innervates the muscles of facial expression. Choices A, B, and C are incorrect as they are not specific to cranial nerve VII assessment. The turning of the head against resistance (A) would be more related to cranial nerve XI, the accessory nerve. The tongue position (B) is controlled by cranial nerve XII, the hypoglossal nerve. Pupillary constriction in response to light (C) is regulated by cranial nerve II, the optic nerve.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
- A. The client takes an antihypertensive medication.
- B. The client has electrical wires secured to baseboards.
- C. The client wears rubber-sole shoes.
- D. The client's visual acuity is 20/40.
Correct Answer: A
Rationale: The correct answer is A because taking antihypertensive medication can lead to orthostatic hypotension, increasing fall risk. Choice B is incorrect as securing electrical wires actually reduces tripping hazards. Choice C is incorrect as rubber-sole shoes provide better traction. Choice D is incorrect as 20/40 visual acuity alone may not directly contribute to fall risk.