Nokea
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.
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The nurse evaluates a client's knowledge as deficient when the client makes which of the following statements about the drug dexamethasone (Decadron)?
- A. I cannot stop the Decadron all at one time.'
- B. If I forget a dose, it's no big deal; I'll just take it when I remember it.'
- C. When I get a cold, I need to let my doctor know.'
- D. I need to watch for an allergic reaction when I first start taking Decadron.'
Correct Answer: B
Rationale: Dexamethasone requires consistent dosing, and missing a dose can have significant effects, indicating a need for further instruction.
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
The nurse is assessing a client with suspected dehydration. Which of the following findings would support this diagnosis? Select all that apply.
- A. Sunken fontanelles in an infant.
- B. Tachycardia.
- C. Increased urine specific gravity.
- D. Dry skin.
- E. Hypotension.
Correct Answer: A, B, C, D, E
Rationale: Dehydration presents with sunken fontanelles, tachycardia, increased urine specific gravity, dry skin, and hypotension due to fluid loss.
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, 'How could God do this to me? I've never done anything wrong.' Which of the following responses by the nurse would be most appropriate at this time?
- A. God can handle your anger. It's okay.'
- B. I know you are angry. It's so hard to lose your baby.'
- C. It's not God's fault. It was an accident.'
- D. You're a strong person. You will get through this.'
Correct Answer: B
Rationale: Acknowledging the client's anger and the difficulty of the loss validates their emotions and provides empathetic support, which is most appropriate in this situation. Option A may dismiss the client's feelings, C shifts focus inappropriately, and D assumes strength without addressing the emotional impact.