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 parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
- A. Have you recently visited the zoo? Maybe the tigers looked scary.
- B. If you agree with your child, the fears could continue through this developmental stage.
- C. Night fears are common at this age. Look under the bed with your child.
- D. This is very unusual. Maybe the child saw something scary on TV.
Correct Answer: C
Rationale: Night fears are normal in preschoolers (C). Checking under the bed with the child validates their fear while showing safety. Linking to a zoo visit (A) or media (D) assumes unconfirmed triggers. Agreeing with fears (B) may reinforce them.
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.
The nurse is talking with the parent of a 5-year-old client who is receiving morphine for pain. Which of the following statements by the parent would be a priority to follow up?
- A. My child may act aggressively when experiencing pain.
- B. I am concerned that my child thinks the pain is punishment.
- C. The FACES pain scale can be used to monitor my child's pain level.
- D. My child is playing and therefore does not need any pain medication now.
Correct Answer: D
Rationale: Assuming a playing child has no pain (D) is incorrect, as children may play despite pain. This requires follow-up to ensure adequate pain management. Aggression (A) and feeling punished (B) are valid concerns but less urgent. Using the FACES scale (C) is appropriate.
A new mother asks the nurse when the baby's umbilical cord will fall off. The nurse replies that it usually takes how many days to detach?
- A. 1-2 days
- B. 3-5 days
- C. 7-10 days
- D. 15-20 days
Correct Answer: C
Rationale: The umbilical cord typically detaches within 7-10 days as it dries and separates naturally, a standard newborn care fact.
The charge nurse in a long-term care facility is making assignments. When assigning personnel to care for residents, which principle is important?
- A. Assignments should be rotated on a daily basis.
- B. Clients who are confused often do better with the same caregiver for several days.
- C. Female caregivers should not care for male residents.
- D. Caregivers should be allowed to select the residents they will care for.
Correct Answer: B
Rationale: Consistency with caregivers reduces anxiety and improves trust for confused clients, enhancing care quality. Daily rotation, gender restrictions, or caregiver choice are less effective.