1. A nurse is reinforcing discharge teaching about wound care
with a family member of a client who is postoperative.
Which of the following should the
... [Show More] nurse include in the
teaching?
a) Administer an analgesic following wound care. (The nurse
should remind the family member to administer an analgesic
prior to wound care to prevent discomfort.)
b) Irrigate the wound with povidone iodine. (The nurse should
remind the family member to irrigate the wound with 0.9%
sodium chloride.)
c) Cleanse the wound with a cotton-tipped applicator. (The nurse
should remind the family member to avoid using a cottontipped
applicator to cleanse the wound because the fibers can
become embedded in the wound, cause infection, and delay
wound healing.)
d) Report purulent drainage to the provider. (The nurse should
remind the family member to report signs of infection,
including purulent drainage.)
2. A nurse is caring for a client who has bacterial meningitis.
Upon monitoring the client, which of the following findings
should the nurse expect?
a) Flaccid neck (The nurse should recognize that nuchal rigidity,
rather than a flaccid neck, is a manifestation of meningitis.)
b) Stooped posture with shuffling gait (The nurse should recognize
that a stooped posture with shuffling gait is a manifestation of
Parkinson's disease, not a manifestation of meningitis.)
c) Red macular rash (The nurse should expect to find a red
macular rash, sometimes called a petechial rash, which is a
manifestation of meningococcal meningitis.)
d) Masklike facial expression (The nurse should recognize that a
masklike expression is a manifestation of Parkinson's disease,
not a manifestation of meningitis.)
3. A nurse is contributing to the plan of care for an older adult
client who is at risk for osteoporosis. Which of the following
interventions should the nurse include to prevent bone
loss?
a) Increase fluid intake. (Fluid intake is beneficial for general
health and wellness, and it helps to treat some disorders.
Caffeine and alcohol intake can increase the client's risk of
developing osteoporosis. However, fluid intake does not prevent
bone loss.)
b) Encourage range-of-motion exercises. (Range-of-motion
exercises are beneficial for general health and wellness, and
they help to maintain flexibility and prevent contractures.
However, range-of-motion exercises do not prevent bone loss.)
c) Massage bony prominences. (Massaging bony prominences
should be avoided because it can traumatize deep tissues.)
d) Encourage weight-bearing exercises. (Weight-bearing exercises,
such as walking, can maintain bone mass by reducing bone
demineralization, thus helping to prevent osteoporosis.)
4. A nurse is collecting data from a client and notices several
skin lesion. Which of the following findings should the
nurse report as possible melanoma?
a) Scaly patches (The nurse should report scaly patches as possible
basal or squamous cell carcinoma.
b) Silvery white plaques (The nurse should report silvery white
plaques as possible psoriasis.)
c) Irregular borders (The nurse should report irregular borders of
a skin lesion to the provider because it can indicate malignant
melanoma.)
d) Raised edges (The nurse should report raised edges of a skin
lesion as possible basal cell carcinoma.)
5. A nurse is reinforcing discharge teaching to prevent
dumping syndrome for a client following a partial
gastrectomy for ulcers. Which of the following information
should the nurse include in the teaching?
a) Avoid liquids at mealtimes. (The nurse should remind the client
to avoid drinking liquids at mealtimes to prevent the food from
emptying into the small bowel too quickly.)
b) Exclude eating starchy vegetables. (The nurse should remind
the client to include starchy vegetables in the meal plan to slow
gastric emptying.) [Show Less]