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Questions 164

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Question 1 of 5

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?

Correct Answer: B,D

Rationale: Cleansing the wound with normal saline (
B) removes contaminants, and hand hygiene with gloves (
D) ensures sterility. Applying ointment before the culture (
A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (
C) may not target active infection.

Question 2 of 5

The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?

Correct Answer: D

Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.

Question 3 of 5

The best position for the client with a right total hip replacement is:

Correct Answer: C

Rationale: Supine with pillows supporting the leg prevents dislocation while maintaining alignment. Flexion or adduction risks complications.

Question 4 of 5

The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures?

Correct Answer: A

Rationale: Mechanical valve replacements (
A) require prophylactic antibiotics before dental procedures to prevent endocarditis. Mitral valvuloplasty (
B), heart failure (
C), and mitral valve prolapse with regurgitation (
D) have lower risks.

Question 5 of 5

A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:

Correct Answer: C

Rationale: The symptoms suggest a pulmonary embolus, a medical emergency. Placing the client in high Fowler's position facilitates breathing. Oxygen is secondary, chest compressions are inappropriate without cardiac arrest, and sedatives could worsen respiratory distress.

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