Nokea
When describing the correct way for cleansing a wound site, the nurse understands that the wound should be cleaned:
- A. From the top to the bottom two times, with the swab discarded
- B. From the outermost region to the center
- C. With circular motions from the drainage site to the outermost edges
- D. With normal saline followed by an astringent wash
Correct Answer: C
Rationale: Cleaning from the drainage site outward prevents spreading pathogens. Other methods risk contamination or are inappropriate.
You may also like to solve these questions
The nurse is assessing a client with complaints of right lower quadrant pain.
- A. Which assessment technique should the nurse use first to assess a client with right lower quadrant pain?
- B. Inspect the abdomen for distention or masses.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen for tympany or dullness.
- E. Palpate the abdomen for tenderness or rebound.
Correct Answer: A
Rationale: Inspection is the first step in abdominal assessment, allowing the nurse to observe for distention, masses, or visible abnormalities before proceeding to auscultation, percussion, and palpation. Palpation last prevents discomfort that could alter other findings.
The nurse is caring for a client with a history of type 2 diabetes who is receiving insulin aspart (NovoLog) 10 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 80 mg/dL.
- B. Heart rate of 90 bpm.
- C. Sweating and shakiness.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Sweating and shakiness indicate hypoglycemia, a serious complication of insulin aspart, requiring immediate treatment with carbohydrates. Options A, B, and D are less concerning: glucose 80 mg/dL is normal, heart rate 90 bpm and blood pressure 130/80 mmHg are stable.
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
- A. Total protein $40 \mathrm{mg} / 100 \mathrm{~mL}$
- B. Glucose $60 \mathrm{mg} / 100 \mathrm{~mL}$
- C. Clear, colorless appearance
- D. White blood cells $100 / \mathrm{cu}$. $\mathrm{mm}$
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication at the first sign of a headache.
- B. I should avoid driving after taking this medication.
- C. I should report chest pain to my doctor.
- D. I should take this medication every morning to prevent headaches.
Correct Answer: D
Rationale: Taking sumatriptan daily to prevent migraines is incorrect, as it is used to abort acute attacks, not for prophylaxis. Options A, B, and C are correct: early use maximizes efficacy, sedation may impair driving, and chest pain may indicate vasoconstriction.
A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?
- A. Patient signs an informed consent form
- B. Patient is given morning medications
- C. Patient gets a good night's sleep
- D. Patient has a good breakfast
Correct Answer: A
Rationale: An informed consent is required prior to surgery.