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The nurse is preparing to physically exam a client. What action by the nurse is most to take prior to beginning the client examination?

Wash hands prior to examination in the examination room.

Approach the client from the left side of the examination table.

Recap used needles and place them in the sharps container.

Remove gloves only after the examination is over.

Answer and Explanation

The Correct Answer is A

A. Hand hygiene is the most important action to prevent the spread of infection before any physical examination.

B. Approaching from the left side is unnecessary unless required by specific patient needs.

C. Needles should never be recapped as this increases the risk of needlestick injuries.

D. Gloves should be worn when appropriate but should not be the first action before an examination. Hand hygiene is essential before touching the client or any instruments.

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Correct Answer is B

Explanation

A. Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B. The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C. The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

Correct Answer is ["675"]

Explanation

To calculate the dosage of vancomycin, first convert the client's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The client weighs 198 pounds, which is approximately 90 kilograms (198 ÷ 2.2). The prescribed dose is 15 mg/kg/day, so for a 90 kg individual, this would be 1350 mg/day (90 kg × 15 mg/kg). Since the dosage is divided equally every 12 hours, the nurse would administer half of the daily dosage per dose, resulting in 675 mg every 12 hours (1350 mg/day ÷ 2). Therefore, the nurse should administer 675 mg with each dose.

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The nurse is preparing to physically exam a client. What action by the nurse is most to take prior to beginning the client examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Correct Answer is B

Explanation

A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["675"]

Explanation

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