Nokea
The nurse is to change a dressing. Which is essential to do when opening the dressing set?
- A. Open the first flap away from the nurse.
- B. Open the first flap toward the nurse.
- C. Place the dressing set on a chair beside the bed.
- D. Place the dressing set on the client's bed.
Correct Answer: A
Rationale: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.
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Laboratory results
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female:
12-16 g/dL
(120-160 g/L)
5 g/dL
The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.
- A. Coarse crackles
- B. Dyspnea
- C. Pallor
- D. Respiratory depression
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (B), pallor (C), and tachycardia (E) as compensatory mechanisms. Crackles (A) suggest fluid overload, and respiratory depression (D) is unrelated.
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.
A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
- A. Serum potassium
- B. Protein intake
- C. Lactose tolerance
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.
Which meal should the nurse recommend for a client at 13 weeks gestation?
- A. Baked chicken, turnip greens, peanut butter cookie, and grape juice
- B. Baked swordfish, fries, baked apples, and fat-free milk
- C. Chilled ham and cheese sandwich, broccoli, orange slices, and water
- D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water
Correct Answer: A
Rationale: Baked chicken, greens, cookie, and juice (A) provide balanced nutrients without high-mercury fish (B), deli meats (C), or undercooked liver (D), which pose risks in pregnancy.
An adolescent client has been hospitalized for 2 months for an eating disorder. She asks the nurse what to tell her classmates about her long absence. The nurse can best help the client by:
- A. Having her practice changing the subject when asked personal questions
- B. Helping her invent a believable explanation for her absence
- C. Engaging her in role playing activities that are likely to occur
- D. Encouraging her to share her experiences with those who ask
Correct Answer: C
Rationale: Role-playing helps the client prepare for social interactions, building confidence in handling questions about her absence.