Nokea
The wound irrigation process cleanses the wound and:
- A. Reduces the potential pain in the wound region or area.
- B. Stops the spread of infection by creating a 'clean' area.
- C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
- D. Allows for the introduction of medications in solution form.
Correct Answer: D
Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.
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A nurse on a med-surg unit is caring for a group of clients with the assistance of an LPN and an AP. Which of the following tasks should the nurse assign to the LPN?
- A. Reinforce dietary teaching with a client who has heart disease.
- B. Obtaining a urine specimen from an older adult client
- C. Providing postmortem care for a client who has just died.
- D. Accompanying a client who just had a wound debridement to PT.
Correct Answer: A
Rationale: The correct answer is to reinforce dietary teaching with a client who has heart disease. This task falls within the LPN's scope of practice as they can provide education and support related to nutrition. Obtaining a urine specimen (Choice B) is typically performed by nursing assistants. Providing postmortem care (Choice C) is a sensitive task usually performed by registered nurses. Accompanying a client to physical therapy (Choice D) is often done by nursing assistants or other supportive staff.
While administering penicillin intravenously, you notice that the patient becomes hypotensive with a bounding, rapid pulse rate. What is the first action you should take?
- A. Decrease the rate of the intravenous medication flow.
- B. Increase the rate of the intravenous medication flow.
- C. Call the doctor.
- D. Stop the intravenous flow.
Correct Answer: D
Rationale: The correct action to take when a patient becomes hypotensive with a bounding, rapid pulse rate after administering penicillin intravenously is to stop the intravenous flow immediately. This can help prevent further complications by discontinuing the administration of the medication that might be causing the adverse effects. Decreasing or increasing the rate of medication flow may not address the underlying issue of the patient's adverse reaction. While it's important to involve the healthcare provider in such situations, the immediate priority is to halt the administration of the medication.
Wilms' tumor is a form of:
- A. Renal cancer.
- B. Liver cancer.
- C. Basal cell carcinoma.
- D. Brain cancer.
Correct Answer: A
Rationale: Wilms' tumor is a type of kidney cancer that primarily affects children. The correct answer is A: Renal cancer. This tumor originates in the kidneys and is most commonly found in children, with the peak incidence around 3-4 years of age. Choice B, Liver cancer, is incorrect as Wilms' tumor specifically involves the kidneys, not the liver. Choice C, Basal cell carcinoma, is a form of skin cancer, not related to Wilms' tumor. Choice D, Brain cancer, is incorrect as Wilms' tumor is not associated with the brain but rather with the kidneys.
A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?
- A. If you have the procedure now, you won't have to deal with pain and disability later.
- B. You'll be fine. You'll receive a prescription for pain medication.
- C. Why didn't you discuss your concerns with your provider?
- D. I understand and it's not too late to change your mind.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Dr. Shrunk orders intravenous (IV) insulin for Rita, a client with a blood sugar of 563. Nurse AJ administers insulin lispro (Humalog) intravenously (IV). What does the best evaluation of the nurse reveal? Select one that does not apply.
- A. The nurse could have given the insulin subcutaneously.
- B. The nurse did not have to contact the physician.
- C. The nurse should have used regular insulin (Humulin R).
- D. The nurse used the correct insulin.
Correct Answer: C
Rationale: The best evaluation of the nurse reveals that she should have used regular insulin (Humulin R) for IV administration. Regular insulin is the only insulin approved for intravenous administration due to its pharmacokinetic properties. Insulin lispro (Humalog) is not suitable for IV use. Choice A is incorrect because giving insulin intravenously is necessary in this case of high blood sugar. Choice B is incorrect because administering a different insulin without consulting the physician is not appropriate. Choice D is incorrect because the nurse used the incorrect insulin, which could pose risks to the client's health.