Nokea
When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a:
- A. Plastic zip-lock bag
- B. Rubber tote
- C. Paper bag
- D. Padded manila envelope
Correct Answer: C
Rationale: A paper bag allows air circulation, preventing moisture that could degrade biological evidence.
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An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
- A. tunneling.
- B. dehiscence.
- C. undermining.
- D. evisceration.
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
A post-operative client with an abdominal wound tries to reach over and take a book off the bedside table. He immediately screams and calls for the nurse. The nurse notices serosanguineous drainage coming from the incision on the abdomen. The first action the nurse should take is to
- A. cover the incision with a sterile cloth or dressing.
- B. lower the head of the bed to less than 10 degrees.
- C. check the client's vitals to assess for drop in blood pressure.
- D. call and alert the surgeon.
Correct Answer: A
Rationale: Covering the incision with a sterile dressing prevents contamination and infection, which is the immediate priority. Assessing vitals or notifying the surgeon follows after stabilizing the wound.
According to Maslow's hierarchy of needs, 'lack of prejudice' falls under which level of human need fulfillment?
- A. love and belonging
- B. self-actualization
- C. safety
- D. esteem
Correct Answer: B
Rationale: Lack of prejudice reflects self-actualization, Maslow’s highest level, where individuals achieve personal growth and acceptance of others.
The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
- A. Frequent dental visits
- B. Frequent lab work
- C. Additional fluids
- D. Additional sodium
Correct Answer: B
Rationale: Depakote requires regular lab monitoring (e.g., liver function, platelet counts) to detect potential side effects like hepatotoxicity or thrombocytopenia.