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What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
- A. Check capillary refill of toes on the lower extremity with the Unna's paste boot.
- B. Apply dressing to the wound area before applying the Unna's paste boot.
- C. Wrap the leg from the knee down towards the foot.
- D. Remove the Unna's paste boot every 8 hours to assess wound healing.
Correct Answer: A
Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.
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The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct Answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct Answer: B
Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.
The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?
- A. Raise the bed to a comfortable working level.
- B. Bend the client's knee.
- C. Move the knee toward the chest as far as it will go.
- D. Cradle the client's heel.
Correct Answer: D
Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.
What is the most effective way to implement a teaching plan?
- A. Teach the information that the learner wants to learn first.
- B. Streamline the teaching plan to include only essential information.
- C. Present to the learner all the necessary information to meet the objectives.
- D. Provide the learner with written material to review before teaching sessions.
Correct Answer: A
Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.
A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?
- A. Number of staff-induced injuries
- B. Client satisfaction survey
- C. Healthcare-associated infection rate
- D. Rate of needle-stick injuries by nurses
Correct Answer: C
Rationale: The correct answer is C - Healthcare-associated infection rate. Acrylic nails can harbor bacteria, increasing the risk of healthcare-associated infections. By implementing a policy to remove acrylic nails, the goal is to reduce the infection rate. Monitoring the healthcare-associated infection rate will provide a direct measure of the policy's effectiveness in achieving its intended outcome. This measure is more specific and directly related to the objective of reducing the risk of infections compared to the other choices.