A nurse is replacing the surgical dressings on a A nurse is changing the dressings for a client
client who had abdominal surgery. Which of the who has two Penrose drains near an abdominal
following actions should the nurse take? - incision. Which of the following adhering devices
ANSWER -Don clean gloves to remove the is the best choice for the nurse to use to
old dressing decrease skin irritation? - ANSWER -
Montgomery straps
A nurse is caring for a client who had a
mastectomy and has a self-suctioning drainage A nurse is preparing to administer an
evacuator in place. Which of the following actions intramuscular injection to a client who is
should the nurse take to ensure proper operation overweight. Which of the following sites should
of the device? - ANSWER -Collapse the the nurse select for the injection? -
device of air after emptying ANSWER -The side hip between the iliac
crest and anterior iliac spine
A nurse is collecting a urine specimen for culture
and sensitivity for a client who has a urinary tract A nurse is caring for a client who has an NG tube
infection. The client has an indwelling urinary for intermittent enteral feedings. Which of the
catheter in place. Which of the following actions following actions should the nurse take? -
should the nurse take? - ANSWER -Clamp ANSWER -Elevate the clients head of the
the tubing below the collection port bed 45 degrees before the feeding
A nurse is providing teaching to a group of unit A nurse is changing the dressings for a client
nurses about wound healing by secondary recovering from an appendectomy following a
intention. Which of the following information ruptured appendix. The client's surgical wound is
should the nurse include in the teaching? - healing by secondary intention. Which of the
ANSWER -Granulation tissue fills the following observations should the nurse report to
wound during healing the provider? - ANSWER -A halo of
erythema on the surrounding skin
A nurse is providing teaching to a client who has
a new colostomy about proper care. Which of the A nurse is performing eye irrigation for a client
following information should the nurse include in who was exposed to smoke and ash. Which of
the teaching? - ANSWER -Cleanse the skin the following actions should the nurse take? -
around the stoma with warm water ANSWER -Exert pressure on the bony
prominences when holding the eyelids open
A nurse is helping a client change his hospital
gown. The client has an IV infusion on an A nurse is assessing a client who has an onset of
infusion pump. Which of the following actions severe back pain of unknown origin. Which of the
should the nurse take first? - ANSWER - following questions should the nurse ask to
Remove the sleeve of the gown from the arm encourage discussions with the client? -
without the IV line ANSWER -"What do you think caused the
onset of your pain?"
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