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What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct Answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.
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A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?
- A. History of gastrointestinal bleeding
- B. Prothrombin time of 12 seconds
- C. Platelet count of 180,000/mm³
- D. Creatinine level of 1.0 mg/dL
Correct Answer: A
Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.
Which assessment finding is expected with myxedema?
- A. Increased pulse rate
- B. Decreased temperature
- C. Fine tremors
- D. Weight loss
Correct Answer: B
Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.
A client who is postpartum is being taught about breast care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wear tight-fitting bras to reduce discomfort
- B. I will nurse my baby frequently to prevent engorgement
- C. I will pump my breasts every 4 hours
- D. I will avoid nursing for at least 48 hours
Correct Answer: B
Rationale: The correct answer is B. Nursing the baby frequently helps prevent engorgement and discomfort in breastfeeding mothers. Choice A is incorrect because tight-fitting bras can lead to clogged milk ducts and worsen discomfort. Choice C may lead to oversupply issues and is not necessary unless there is a specific indication. Choice D is incorrect as avoiding nursing for extended periods can lead to engorgement and decreased milk supply.
How should a healthcare professional assess a patient with potential pneumonia?
- A. Assess lung sounds and monitor oxygen saturation
- B. Monitor for fever and sputum production
- C. Auscultate heart sounds and check for cyanosis
- D. Monitor for chest pain and administer oxygen
Correct Answer: A
Rationale: Correctly assessing a patient with potential pneumonia involves listening to lung sounds and monitoring oxygen saturation. Lung sounds can reveal abnormal breath sounds associated with pneumonia, such as crackles or diminished breath sounds. Oxygen saturation monitoring helps in detecting respiratory distress, a common complication of pneumonia. Monitoring for fever and sputum production (Choice B) is important but not as specific as assessing lung sounds and oxygen saturation. Auscultating heart sounds and checking for cyanosis (Choice C) are not primary assessments for pneumonia. Monitoring for chest pain and administering oxygen (Choice D) are relevant interventions but do not address the initial assessment of pneumonia.
A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?
- A. Frequent hand washing prevents infection
- B. Prolonged use of corticosteroids increases infection risk
- C. Limit patient interaction to reduce infection spread
- D. Restrict client movement to prevent contamination
Correct Answer: B
Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.