Exhibits

The practical nurse (PN) is preparing to change the turban dressing.

For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

Clean the site using sterile gauze and sterile water.

Place client in a private room.

Avoid hand sanitizer after the procedure.

Place the soiled dressing in a red biohazard bag.

Use sterile gloves to remove

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Clean the site using sterile gauze and sterile water.
- Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
Place client in a private room.
- Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
Avoid hand sanitizer after the procedure.
- Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
Place the soiled dressing in a red biohazard bag.
- Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
Use sterile gloves to remove the old dressing.
- Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

A. Administer half of the missed dose immediately. B. Give the missed dose with the next scheduled dose. C. Withhold the missed dose unless seizure activity occurs. D. Administer the missed dose as soon as possible.

Correct Answer is D

Explanation

A. Administering half of the missed dose is not generally recommended because it could lead to inconsistent drug levels and potential for breakthrough seizures. The standard practice is to follow the dosing schedule unless otherwise instructed by the healthcare provider.
B. Giving the missed dose with the next scheduled dose may lead to double dosing and could increase the risk of side effects or toxicity. The missed dose should be addressed as soon as possible but not in combination with the next dose.
C. Withholding the missed dose unless seizure activity occurs could put the client at risk for seizures. Anticonvulsants should be administered as per the prescribed schedule to maintain therapeutic drug levels and prevent seizures.
D. Administering the missed dose as soon as possible is the correct approach, following standard guidelines for missed medications. The missed dose should be given promptly unless it is close to the time of the next dose, in which case the next dose should be given as scheduled.

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Exhibits The practical nurse (PN) is preparing to change the turban dressing. For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

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

Explanation

At 1200, the practical nurse (PN) learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

Correct Answer is D

Explanation

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

Exhibits Which intervention(s) should the practical nurse (PN) initiate if elder mistreatment is suspected? Select all that apply.

An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?

The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend?

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

Exhibits Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action?

Which assessment finding indicates to the practical nurse that a Venturi face mask is producing the desired effect?

Exhibits

The practical nurse (PN) is preparing to change the turban dressing.

For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one