Complete Practice Question Bank with
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1. The nurse is performing a baseline assessment of a client's skin
integrity.
Which of the following is a key assessment parameter?
1. Family history of pressure ulcers
2. Presence of existing pressure ulcers
3. Potential areas of pressure ulcer development
4. Overall risk of developing pressure ulcers: Correct Answer: 4
RATIONALES: When assessing skin integrity, the overall risk potential
for developing pressure ulcers takes priority.
Overall risk encompasses existing pressure ulcers as well as potential
areas for development of pressure ulcers. Family
history isn't important when assessing skin integrity.
2. The physician prescribes penicillin potassium oral suspension 56
mg/kg/day
in four divided doses for a client with anorexia nervosa who weighs 25
kg.
The medication dispensed by the pharmacy contains a dosage strength
of 125
,mg/5 ml. How many milliliters of solution should the nurse administer
with
each dose?: Correct Answer: 14
RATIONALES: To determine the total daily dosage, set up the following
proportion:
25 kg/X = 1 kg/56 mg
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X = 1,400 mg.
Next, divide the daily dosage by four doses to determine the dose to
administer every 6 hours:
X = 1,400 mg/4 doses
X = 350 mg/dose.
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting up this
proportion:
X/350 mg = 5 ml/125 mg
X = 14 ml.
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4. The nurse must irrigate a gaping abdominal incision with sterile
normal
saline, using a piston syringe. How should the nurse proceed?
1. Irrigate continuously until the solution becomes clear or all of the
solution
has been used.
2. Moisten the area around the wound with normal saline after the
irrigation.
3. Apply a wet-to-dry dressing to the wound after the irrigation.
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4. Rapidly instill a stream of irrigating solution into the wound.: Correct
Answer: 1
RATIONALES: To wash away tissue debris and drainage effectively, the
nurse should irrigate the wound until the solution
becomes clear or all of the solution has been used. After the irrigation,
the nurse should dry the area around the
wound; moistening it promotes microorganism growth and skin
irritation. When the area is dry, the nurse should apply
a sterile dressing, rather than awet-to-dry dressing. The nurse always
should instill the irrigating solution gently; rapid
, or forceful instillation can damage tissues.
5. A client is to have an epidural block to relieve labor pain. The nurse
anticipates
that the anesthesiologist will inject the anesthetic agent into the:
1. subarachnoid space.
2. area between the subarachnoid space and the dura mater.
3. area between the dura mater and the ligamentum flavum.
4. ligamentum flavum.: Correct Answer: 3
RATIONALES: For an epidural block, the nurse should anticipate that the
anesthesiologist will inject a local anesthetic
agent into the epidural space, located between the dura mater and the
ligamentum flavum in the lumbar region
of the spinal column. When administering a spinal block, the
anesthesiologist injects the anesthetic agent into the
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subarachnoid space. The ligamentum flavum and the area between the
subarachnoid space and the dura mater are
inappropriate injection sites.
6. As an adolescent is receiving care, he's inadvertently injured with a
warm
compress. The nurse completes an incident report based on the
knowledge