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A client asks the nurse to provide examples of foods rich in vitamin C. Which food is a good
source of vitamin C?
1. Apple juice.
2. Oatmeal.
3. Lean chicken.
4. Tomatoes. - ✔✔✔-4. Tomatoes.
Tomatoes and other fresh vegetables and fruits, including citrus fruits, apricots, and
strawberries are excellent sources of vitamin C.
A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. Which
client statement indicates to the nurse a correct understanding of medical asepsis?
1. "I need to buy sterile gloves to redress this wound."
2. "I should wash my hands before redressing my wound."
3. "I need to keep the wound covered at all times."
4. "I will use an over-the-counter antimicrobial ointment." - ✔✔✔-2. "I should wash my hands
before redressing my wound."
This response indicates understanding of asepsis. Washing hands is the hallmark of aseptic
technique.
A client is admitted to the medical unit with a temperature of 101°F (38.3°C) and a white blood
cell (WBC) count of 3,000/mm (3 X 10%/L). The nurse institutes which precautions?
1. Contact precautions.
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2. Airborne precautions.
3. Droplet precautions.
4. Neutropenic precautions. - ✔✔✔-4. Neutropenic precautions.
This client has severe neutropenia and is immunosuppressed. The purpose in placing the client
on neutropenic precautions is to prevent infection. The nurse will place the client in private
room. High quality hand washing before touching the client and any of the client's belongings is
critical. The nurse will limit the number of healthcare professionals caring for client to decrease
exposure. Additionally, no fresh flowers or potted plants will be able to remain in the client's
room because of the increase risk of an aspergillus infection.
A client requires a dressing change. The LPN/LVN assigned to care for the client reports never
having performed the procedure before to the nurse. The nurse takes which action?
1. Tells the LPN/LVN to review the hospital's procedure manual prior to performing the dressing
change.
2. Verbally reviews the steps of the dressing change with LPN/LVN.
3. Completes the dressing change while the LPN/LVN observes.
4. Assigns a more experienced LPN/LVN to the client. - ✔✔✔-3. Completes the dressing change
while the LPN/LVN observes.
Allowing the LPN/LVN to observe the nurse complete the dressing change accomplishes two
goals: Completing the dressing change and helping the LPN/LVN to learn how to do the
procedure.
A client returns from surgery with a drain sutured into the surgical wound. Which explanation is
the purpose of the drain?
1. It decreases fluid accumulation within the tissues.
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2. It prevents infection by providing a means for bacteria to escape.
3. It provides hemostasis.
4. It creates a space that will facilitate reconstructive surgery. - ✔✔✔-1. It decreases fluid
accumulation within the tissues.
It is important that blood or serous drainage does not collect underneath the skin edges
otherwise the tissues will not be able to heal properly.
A client with acute pain has a prescription for morphine sulfate 8 mg IV every 3-4 hours as
needed for pain. The client asks the nurse for the medication at bedtime. Prior to administering
the pain medication, the nurse takes which initial action?
1. Assumes the pain is psychological.
2. Checks to see if the client has a history of addiction.
3. Tries several other pain relief measures.
4. Assesses location, character, and intensity of pain. - ✔✔✔-4. Assesses location, character,
and intensity of pain.
When the client reports pain or requests a medication for pain, the nurse should first determine
the onset, duration, and sequence of pain as well as the location and intensity.
A two day postoperative client reports pain, tenderness, and redness of the right calf. Which
findings are most critical for the nurse to report to the health care provider?
1. Nausea and abdominal distention.
2. Back pain and hematuria.
3. Chest pain and shortness of breath.
4. Mild redness around the surgical incision. - ✔✔✔-3. Chest pain and shortness of breath.