A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Uses normal saline to irrigate the wound.

Cleans from less soiled to more soiled areas.

Opens a sterile package towards the body.

Places soiled dressing in a plastic bag.

Answer and Explanation

The Correct Answer is C

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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Correct Answer is D

Explanation

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["A","C","D"]

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

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A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Correct Answer is D

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?