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 assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
The nurse is talking with the parents of a 4-year-old client. The parents are concerned because the client was previously toilet trained but has started wetting the bed again while hospitalized. Which of the following responses would be most appropriate for the nurse to make?
- A. Reinforcing any forgotten toileting behaviors during the hospital stay is beneficial.
- B. Restricting your child's fluid intake at night will resolve this issue.
- C. Your child may be purposefully misbehaving to gain your attention during the hospital stay.
- D. Your child may be reverting to behaviors from an earlier stage of development to cope with stress.
Correct Answer: D
Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress (D). Reinforcing toileting behaviors (A) may help but doesn't address the underlying cause. Fluid restriction (B) is not appropriate without medical indication. Assuming misbehavior (C) dismisses the emotional impact of hospitalization.
An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?
- A. I brought a copy of the completed form with me.
- B. I am glad I don't have to make decisions about my care anymore.
- C. My husband is the one who gets to make decisions for me.
- D. My children all have copies of the living will.
Correct Answer: B
Rationale: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.
The nurse is caring for a woman who has internal radiation for cancer of the cervix. Which of the following situations poses the greatest risk for others?
- A. The client's daughter spends several hours sitting next to the client's bed.
- B. The client's husband kisses her and visits for five minutes before leaving.
- C. The nurse brings the client her lunch tray and sets it up on the overbed table for her.
- D. The cleaning lady damp mops the room.
Correct Answer: A
Rationale: Prolonged close contact (daughter's hours-long visit) increases radiation exposure risk. Brief visits, tray setup, or mopping pose minimal risk.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.