Nokea
The nurse is making a home visit for a client with an abdominal wound.
When irrigating the draining wound with a sterile saline solution, which of the following sequences would be MOST appropriate for the nurse to follow?
- A. Pour the solution, wash hands, and remove the soiled dressing.
- B. Wash hands, prepare the sterile field, and remove the soiled dressing.
- C. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
- D. Remove the soiled dressing, flush the wound, and wash hands.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hands should be washed first (2) correct-handwashing should be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first
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Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
A child at summer camp comes to see the camp nurse 10 minutes after being stung by a bee. The child complains of tingling around her mouth and tightness in her chest. The nurse's first action is summon help and to:
- A. Administer $\mathrm{O}_2$ at $4 \mathrm{~L} / \mathrm{min}$ by nasal cannula.
- B. Apply a tourniquet proximal to the bee sting and give epinephrine subcutaneously.
- C. Administer $\mathrm{O}_2$ at $6 \mathrm{~L} / \mathrm{min}$ and give Benadryl (Diphenhydramine) $25 \mathrm{mg}$ PO.
- D. Reassure the child that she is only excited due to the sting.
Correct Answer: B
Rationale: Tingling and chest tightness suggest anaphylaxis; epinephrine is the first-line treatment, and a tourniquet may slow venom spread.
A client is admitted with a tentative diagnosis of bladder cancer. Which finding most likely contributed to the development of bladder cancer?
- A. Two PPD cigarette use for 25 years
- B. Frequent urinary tract infections
- C. Employment in the textile industry
- D. A history of renal calculi
Correct Answer: A
Rationale: Cigarette smoking is a significant risk factor for bladder cancer due to the exposure to carcinogenic chemicals excreted in urine. Answer A (two packs per day for 25 years) is the most likely contributor. Answers B, C, and D are less directly associated with bladder cancer development.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
The nurse is caring for a client with a history of anaphylaxis.
- A. Which instruction is most important for a client with a history of anaphylaxis?
- B. Carry an epinephrine auto-injector at all times.
- C. Avoid over-the-counter medications.
- D. Wear loose-fitting clothing.
- E. Monitor blood pressure daily.
Correct Answer: A
Rationale: Carrying an epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Avoiding medications, wearing loose clothing, and monitoring blood pressure are less urgent.