Nokea
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
- A. Which behavior by the LPN/LVN indicates proper wet-to-dry dressing change technique?
- B. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- C. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- D. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- E. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.
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Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance imaging?
- A. The client is an insulin-dependent diabetic.
- B. The client refuses a corner bed.
- C. The client is allergic to shellfish.
- D. The client has a history of asthma.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for MRI contrast dye, requiring further assessment. Diabetes , bed preference , and asthma are not contraindications.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
- A. Hyperextension of the neck with passive shoulder flexion
- B. Flexion of the hip and knees with passive flexion of the neck
- C. Flexion of the legs with rebound tenderness
- D. Hyperflexion of the neck with rebound flexion of the legs
Correct Answer: B
Rationale: Flexion of the hip and knees with passive flexion of the neck. This is a positive Brudzinski's sign, indicative of meningitis.
The nurse is caring for a client with a history of alcoholism.
- A. Which laboratory finding is most concerning for a client with chronic alcoholism?
- B. Serum potassium of 3.2 mEq/L.
- C. Blood urea nitrogen of 18 mg/dL.
- D. Hemoglobin of 13.5 g/dL.
- E. Aspartate aminotransferase (AST) of 150 U/L.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.