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Questions 160

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Question 1 of 5

When changing a sterile abdominal dressing, which nursing actions would violate the principles of asepsis? Select all that apply.

Correct Answer: D,E,F

Rationale: Cleaning from the outer edge toward the center introduces contaminants to the wound, violating asepsis. Reaching across the sterile field and touching the soiled dressing with sterile gloves contaminate the sterile field and gloves, respectively.

Question 2 of 5

The nurse observes a nursing assistant assigned to a client who just returned from having a bronchoscopy. Which action by the nursing assistant would prompt the nurse to intervene?

Correct Answer: B

Rationale: After a bronchoscopy, the client is at risk for airway compromise due to anesthesia or swelling. Offering water before the gag reflex returns can lead to aspiration, requiring intervention.

Question 3 of 5

A client with a history of depression is prescribed sertraline (Zoloft). Which side effect should the nurse monitor for?

Correct Answer: B

Rationale: Insomnia is a common side effect of sertraline, a selective serotonin reuptake inhibitor.

Question 4 of 5

A client with a history of hypertension is prescribed hydrochlorothiazide. Which laboratory value should the nurse monitor closely?

Correct Answer: B

Rationale: Hydrochlorothiazide can cause hypokalemia; monitoring potassium levels is essential.

Question 5 of 5

The nurse is caring for a client with a deep vein thrombosis (DVT). Which position should be avoided?

Correct Answer: C

Rationale: Side-lying with legs bent can impede venous return, worsening DVT.

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