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The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
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The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.
The nurse is providing education to a client who is prescribed terbinafine for onychomycosis affecting the toenails. Which statements by the client demonstrate understanding regarding the teaching about terbinafine? Select all that apply.
- A. Following a successful course of treatment, my chance of getting cured is 90%.
- B. I will have to take terbinafine for 3 to 6 months.
- C. I will need liver function tests before starting terbinafine.
- D. I will take this on an empty stomach to help improve its absorption.
- E. It may cause taste or vision changes, so I will report vision changes to my doctor.
- F. Dark urine, pale stools, and persistent nausea may indicate a serious side effect.
Correct Answer: B,C,E
Rationale: Choice B is correct; terbinafine treatment for toenail onychomycosis typically lasts 3-6 months. Choice C is correct; liver function tests are required before and during treatment due to the risk of hepatotoxicity. Choice E is correct; terbinafine can cause taste or vision changes, and vision changes should be reported. Choice A is incorrect; the cure rate is approximately 70-80%, not 90%. Choice D is incorrect; terbinafine can be taken with or without food, and an empty stomach is not required. Choice F is correct; dark urine, pale stools, and nausea may indicate liver toxicity, a serious side effect.
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
- A. A woman who is 5 months pregnant with no apparent injuries.
- B. A middle-aged man with no injuries who has rapid respirations and coughs.
- C. A 10-year-old with a simple fracture of the humerus who is in severe pain.
- D. A 20-year-old with first-degree burns on her hands and forearms.
Correct Answer: B
Rationale: Rapid respirations and coughing suggest possible smoke inhalation, which can lead to airway compromise and requires urgent evaluation and transport.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
- A. The client assists as much as possible in his care, demonstrating increased participation over time.
- B. The client allows the nurse to complete his care in an efficient manner without interfering.
- C. The client allows his wife to assume total responsibility for his care.
- D. The client allows his wife to complete his care to promote feelings of usefulness.
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.