Nokea
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
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The incidence of Sickle Cell Anemia is higher among black American babies.
The symptoms of sickle cell anemia are not evident until later during infancy because
- A. The baby is fed with milk formula, which is rich in ironbfb.
- B. The infant has a much higher RBC count than children and adult.
- C. Maternal iron is depleted later in infancy.
- D. Infants have more body fluids than any age group.
Correct Answer: C
Rationale: High levels of fetal hemoglobin prevent sickling of red blood cells. The newborn has from 44% to 89% fetal hemoglobin, but this rapidly decreases during the first year, making symptoms evident later.
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
The nurse doing a newborn assessment counts the infant's cord vessel.
In a normal infant there are:
- A. Two vessels: one vein and one artery.
- B. Three vessels: two veins and one artery.
- C. Three vessels: one vein and two arteries.
- D. Four vessels: two veins and two arteries.
Correct Answer: C
Rationale: There are three vessels: one vein (carries oxygenated blood to the fetus) and two arteries (return deoxygenated blood to the placenta) in a normal umbilical cord.
Which of the following findings is most typical of a client with a fractured hip?
- A. Pain in the hip and affected leg
- B. Diminished sensation in the affected leg
- C. Absence of pedal and femoral pulses in the affected extremity
- D. Disalignment of the affected extremity
Correct Answer: A
Rationale: Pain in the hip and leg is the most typical symptom of a hip fracture. Diminished sensation, absent pulses, or disalignment may occur but are less common.