CPNRE Basic Care 5 — Questions and Answers
Question 1: A nurse is applying elastic compression stockings to a client. Which assessment finding would require the nurse to withhold the stockings and notify the physician?
- Mild bilateral ankle edema
- Cool, mottled skin on the lower extremities (Correct answer)
- Slight redness at the top of a previously worn stocking
- Complaint of mild leg fatigue after walking
Correct answer: Cool, mottled skin on the lower extremities
Cool, mottled skin suggests compromised peripheral circulation, and applying compression stockings could further impair blood flow.
Question 2: A nurse is preparing to apply a dry sterile dressing to a wound. After performing hand hygiene and opening the sterile field, the nurse accidentally touches the edge of the sterile drape. What should the nurse do?
- Proceed, as the edge of the sterile field is not considered sterile
- Discard the entire sterile field and start over (Correct answer)
- Use the corner of the drape furthest from the touched edge
- Apply more sterile solution to the contaminated area
Correct answer: Discard the entire sterile field and start over
A contaminated sterile field cannot be made sterile again; the nurse must discard all supplies and establish a new sterile field.
Question 3: A client who is immobile is at risk for contractures. Which nursing intervention is most effective for preventing this complication?
- Positioning the client in a supine position with limbs extended during rest
- Performing passive range-of-motion exercises at least twice daily (Correct answer)
- Applying ice packs to affected joints to reduce inflammation
- Encouraging the client to remain in the position of comfort
Correct answer: Performing passive range-of-motion exercises at least twice daily
Passive range-of-motion exercises maintain joint flexibility and muscle length, directly preventing the development of contractures.
Question 4: A nurse is preparing to transfer a client from the bed to a wheelchair using a gait belt. Where should the nurse position the gait belt?
- Around the client's chest, just below the armpits
- Around the client's waist, over clothing (Correct answer)
- Around the client's hips, below the waist
- Around the client's thighs for maximum leverage
Correct answer: Around the client's waist, over clothing
The gait belt is correctly placed around the client's waist over clothing to provide a secure grip without restricting breathing.
Question 5: A nurse is caring for a client with a wound drain (Jackson-Pratt). The nurse notes the bulb is fully expanded. What is the correct nursing action?
- Leave the drain as is and document the finding
- Empty and recompress the bulb to re-establish suction (Correct answer)
- Remove the drain immediately and apply a pressure dressing
- Irrigate the drain with normal saline to clear the blockage
Correct answer: Empty and recompress the bulb to re-establish suction
A fully expanded Jackson-Pratt bulb means suction has been lost; the nurse must empty the collected drainage and compress the bulb to restore negative pressure.
Question 6: A nurse is caring for an older adult client who refuses to eat the hospital meal. Which response by the nurse best supports the client's autonomy while addressing nutritional needs?
- Explain that the meal must be eaten to maintain strength for recovery
- Ask the client about food preferences and involve a dietitian to offer alternatives (Correct answer)
- Document the refusal and remove the tray without further action
- Contact the family to come and encourage the client to eat
Correct answer: Ask the client about food preferences and involve a dietitian to offer alternatives
Exploring the client's food preferences and collaborating with a dietitian respects autonomy while actively addressing the nutritional deficit.
Question 7: A nurse is caring for a client who has been on bed rest for five days. The client reports calf pain and swelling. Which action should the nurse take first?
- Perform Homans' sign by dorsiflexing the foot to confirm DVT
- Immobilize the limb, discontinue ambulation, and notify the physician immediately (Correct answer)
- Apply a warm compress to the calf to relieve discomfort
- Encourage gentle ambulation to improve circulation
Correct answer: Immobilize the limb, discontinue ambulation, and notify the physician immediately
Calf pain and swelling in an immobile client suggest deep vein thrombosis; ambulation must stop immediately and the physician must be notified to prevent pulmonary embolism.
CPNRE Basic Care 5
A nurse is applying elastic compression stockings to a client.
Which assessment finding would require the nurse to withhold the stockings and notify the physician?