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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Correct Answer is B

Explanation

A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.

A. Administer a prescribed PRN benzodiazepine at the onset of a confused state. B. Ensure that the client is assigned to a room close to the nurses' station. C. Postpone administration of nighttime medications until after 2300. D. Ask family members to remain with the client in the evenings from 1700 to 2000.

Correct Answer is B

Explanation

A. Administering a PRN benzodiazepine is a reactive measure and might not be the best first line of intervention for managing the client's restlessness and confusion, as it does not address the underlying issue.
B. Assigning the client to a room close to the nurses' station can help manage restlessness, confusion, and agitation by ensuring the client is monitored more closely and can receive timely interventions.
C. Postponing nighttime medications might not address the immediate issues of restlessness and confusion, and could potentially disrupt the client's sleep-wake cycle.
D. Asking family members to stay with the client provides support but may not be a feasible or consistent solution for managing the client’s evening agitation and restlessness.

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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

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

Correct Answer is B

Explanation

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

Correct Answer is B

Explanation

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 practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

Exhibits The practical nurse (PN) suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

An older adult client returns to the clinic for a follow-up visit with the healthcare provider for management of depression related to the death of a child, who was killed 6 months ago by a drunk driver. Which finding indicates to the practical nurse (PN) that the client is improving?

A preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) of being really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

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