A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Motor impairment

Pain

The client's culture

Hearing loss

Answer and Explanation

The Correct Answer is B

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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Correct Answer is D

Explanation

A. Discarding the dressing in the bedside trash receptacle without proper containment is unsafe and not compliant with infection control standards.

B. Double-bagging the dressing is unnecessary unless required by facility protocols, but it should still be disposed of in a biohazard waste container.

C. Disposing of the dressing in a standard trash receptacle without proper precautions is not appropriate.

D. A wound dressing saturated with blood and purulent drainage is considered biohazardous and should be disposed of in a biohazard waste container to prevent the spread of infection.

A. Testing visual acuity B. Eliciting the gag reflex C. Checking the pupillary response to light D. Observing for facial symmetry

Correct Answer is C

Explanation

A. Testing visual acuity assesses cranial nerve II (the optic nerve), not cranial nerve III.

B. Eliciting the gag reflex involves cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

C. Cranial nerve III (the oculomotor nerve) controls the constriction of the pupil in response to light, so checking the pupillary response to light is the appropriate assessment for this cranial nerve.

D. Observing for facial symmetry is more related to the function of cranial nerve VII (the facial nerve).

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Correct Answer is D

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is C

Explanation

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?