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: if wet dressing touches skin it could cause skin breakdown
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The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.
- B. I should induce vomiting if my child swallows lighter fluid.
- C. Giving my child water or milk may help dilute the poison.
- D. Proper storage is the key to poison prevention in the home.
Correct Answer: B
Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.
The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?
- A. 50 mL/hr
- B. 62 mL/hr
- C. 125 mL/hr
- D. 137 mL/hr
Correct Answer: C
Rationale: To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.
An 82-year-old woman is being admitted to a long-term care facility. Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale. To determine a Braden Scale score, the nurse evaluates all of the following EXCEPT
- A. nutritional status.
- B. sensory perception.
- C. past history of skin breakdown.
- D. activity level.
Correct Answer: C
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Past history of skin breakdown is not a scored category.
A nurse asks an unlicensed assistive personnel (UAP) to help admit a 22-year-old female client with ulcerative colitis. Which activity is appropriate for the nurse to assign the UAP?
- A. obtain a stool sample
- B. obtain abbreviated history of symptoms for the past 30 days
- C. instruct the client on the reason for undergoing a lower gastric X-ray exam
- D. obtain a sample of gastric contents from nasogastric tube
Correct Answer: A
Rationale: Obtaining a stool sample is within the UAP’s scope, as it is a non-invasive task. Other activities involve assessment or teaching, which require RN expertise.