Nokea
The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?
- A. I will apply the prescribed bacitracin ointment after collecting the wound culture.
- B. I will cleanse the wound by gently flushing it with normal saline.
- C. I will obtain a sample of the drainage accumulated since the last dressing change.
- D. I will perform hand hygiene and apply new gloves before obtaining the wound culture.
- E. I will swab the wound from the outermost margin toward the center.
Correct Answer: B,D
Rationale: Cleansing the wound with normal saline (B) removes contaminants, and hand hygiene with gloves (D) ensures sterility. Applying ointment before the culture (A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (C) may not target active infection.
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The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- A. the muscles
- B. the cerebellum
- C. the kidneys
- D. the leg bones
Correct Answer: A
Rationale: the muscles. Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- 'myo' --which typically means muscle.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?
- A. I have a burning sensation when I urinate.
- B. I have been having some dribbling after I finish urinating.
- C. I missed 3 days of finasteride while on a trip last week.
- D. I was awakened 3 times last night by the need to urinate.
Correct Answer: A
Rationale: Burning on urination (A) suggests a urinary tract infection, requiring investigation. Dribbling (B), nocturia (D), and missing doses (C) are common with BPH or medication non-adherence but less urgent.
The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?
- A. I need to continue to avoid eating spinach and kale.
- B. I probably will have some weakness in my legs when I take this medicine.
- C. I should avoid taking aspirin while receiving this medication.
- D. I will have to get blood drawn routinely to check my clotting levels.
Correct Answer: C
Rationale: Rivaroxaban is a direct oral anticoagulant that does not require routine monitoring of clotting levels, unlike warfarin. It also does not necessitate dietary restrictions like avoiding spinach and kale, which are relevant for warfarin due to vitamin K interactions. Avoiding aspirin is correct because it increases bleeding risk when combined with rivaroxaban. Weakness in legs is not a typical side effect of rivaroxaban.