1
객관식
A nurse is caring for a client with a stage 3 pressure ulcer on the sacrum that is in the proliferative phase of wound healing. Which nursing intervention is most appropriate to promote optimal healing during this phase?
A
Apply a dry sterile dressing to absorb excess drainage
B
Perform aggressive wound irrigation with normal saline
C
Keep the wound bed completely dry to prevent bacterial growth
D
Maintain a moist wound environment and protect the granulation tissue
2
객관식
A nurse is assessing a client who was diagnosed with Bell palsy 2 days ago. Which assessment finding would the nurse expect to observe?
A
Bilateral facial muscle weakness with difficulty speaking
B
Severe headache with photophobia and neck stiffness
C
Muscle spasticity and hyperreflexia on the affected side
D
Unilateral facial drooping with inability to close the eye on the affected side
3
객관식
A nurse is assessing a patient who sustained a blunt trauma to the left eye 2 hours ago. Which assessment finding would be most concerning and require immediate intervention?
A
Mild periorbital swelling and tenderness
B
Severe eye pain with nausea and vomiting
C
Small subconjunctival hemorrhage
D
Slight decrease in visual acuity
4
객관식
A nurse in the emergency department is caring for a 28-year-old client with type 1 diabetes mellitus who presents with nausea, vomiting, abdominal pain, severe dehydration, and rapid, deep respirations. Recognizing these as signs of diabetic ketoacidosis (DKA), which intervention should the nurse implement first?
A
Administer insulin as prescribed
B
Establish IV access and begin fluid resuscitation
C
Monitor blood glucose levels every hour
D
Assess neurological status frequently
5
객관식
A nurse is caring for a client with beta-thalassemia major who requires regular blood transfusions. Which nursing intervention is the priority when preparing for blood transfusion therapy?
A
Verify client identification and blood compatibility with another registered nurse
B
Premedicate the client with acetaminophen to prevent fever
C
Ensure the blood is warmed to room temperature before administration
D
Obtain baseline hemoglobin and hematocrit levels
6
객관식
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy at 2 L/min via nasal cannula. The client's oxygen saturation is 88% and arterial blood gas results show: pH 7.32, PaCO2 58 mmHg, PaO2 55 mmHg, HCO3- 28 mEq/L. Which nursing intervention should the nurse implement first?
A
Increase oxygen flow rate to 4 L/min immediately
B
Encourage deep breathing and coughing exercises
C
Position the client in high Fowler's position
D
Assess respiratory status and notify the healthcare provider
7
객관식
A nurse is preparing to administer the seasonal influenza vaccine to a 45-year-old client. Which assessment finding would require the nurse to postpone the vaccination?
A
Client reports a mild headache that started this morning
B
Client has a fever of 101.2°F (38.4°C) and reports feeling unwell
C
Client mentions having a fear of needles and feeling anxious
D
Client states they received a tetanus vaccine 2 weeks ago
8
객관식
A client arrives at the emergency department with a chemical burn to the right eye from exposure to a strong alkaline cleaning solution. Which nursing intervention should be the immediate priority?
A
Apply a sterile eye patch to prevent further contamination
B
Administer prescribed topical anesthetic drops to reduce pain
C
Initiate continuous irrigation with normal saline or sterile water
D
Obtain a detailed history of the chemical exposure incident
9
객관식
A nurse is caring for a patient with a confirmed MRSA wound infection. Which nursing action demonstrates the most critical safety measure to prevent transmission?
A
Performing hand hygiene with alcohol-based hand rub before and after each patient contact
B
Wearing sterile gloves when changing the wound dressing
C
Placing the patient in a private room with negative air pressure
D
Administering prescribed antibiotics at the exact scheduled times
10
객관식
A nurse is caring for a 65-year-old patient who has been on bed rest for 3 days following spinal surgery. During assessment, the nurse notes stage 1 pressure injury on the patient's sacrum. What is the most appropriate nursing intervention to prevent progression of this pressure injury?
A
Apply a hydrocolloid dressing to the affected area
B
Massage the reddened area gently to improve circulation
C
Keep the area clean and dry with frequent position changes every 4 hours
D
Implement a turning schedule every 2 hours and use pressure-relieving devices