Nokea
A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.
The nurse should intervene in which of the following situations?
- A. The LPN/LVN enters the room wearing a gown and gloves.
- B. The nursing assistant enters the room wearing a mask.
- C. The client's family brings him a milkshake.
- D. The staff lifts the client to reposition him.
Correct Answer: B
Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force
You may also like to solve these questions
The nurse is preparing a client for a skin biopsy.
Which of the following client statements should the nurse report to the physician?
- A. I've been taking aspirin for my sore knees.'
- B. Using lotion has helped my dry skin.'
- C. I went to the tanning salon yesterday.'
- D. I had a big breakfast this morning.'
Correct Answer: A
Rationale: Strategy: Determine how the statements relate to skin biopsy. (1) correct-aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy
A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.