Nokea
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
- A. Use medical aseptic technique.
- B. Leave the wet compress open to the air.
- C. Place both a dry covering and waterproof material over the compress.
- D. Remove the compress after five minutes.
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
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The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings indicates fluid overload?
- A. Blood pressure of 120/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest pulmonary edema from fluid overload. Options A, B, and D are normal findings.
The nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
- A. Of course, I will do as you wish.
- B. I am obligated to try and preserve life.
- C. Do you have advance directives? These need to be in your record.
- D. Be sure to tell each nurse your desires.
Correct Answer: C
Rationale: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.
A 56-year-old woman hospitalized with bipolar disorder. While the patient is in the manic phase.
Nursing interventions should involve
- A. talking to the patient and reinforcing behaviors.
- B. distracting the patient and redirecting behaviors.
- C. limit-setting and isolating the patient.
- D. orienting to and reminding the patient of the rules of the hospital.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct-patient experiences hyperactivity, poor concentration, and distractibility, redirect into activity that promotes rest, nourishment, reduce stimuli (3) isolation not required, would increase anxiety and hostility (4) disorientation usually not seen, no memory disturbance