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A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
- A. Apply a heat lamp twice a day
- B. Cleanse with 0.9% sodium chloride irrigation
- C. Cleanse with povidone-iodine solution
- D. Massage reddened areas during dressing changes
Correct Answer: B
Rationale: 0.9% sodium chloride irrigation is recommended for granulating tissue. Povidone-iodine is cytotoxic and should not be used. Heat lamps and massage can cause further tissue damage.
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A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
A nurse is reinforcing teaching with a newly licensed nurse about using the therapeutic technique of confrontation when caring for a client. Which of the following instructions should the nurse include in the teaching?
- A. Offer the client personal opinions.
- B. Change the subject when talking with the client.
- C. Use an aggressive tone of voice with the client.
- D. Establish a trusting relationship with the client.
Correct Answer: D
Rationale: Confrontation should be used in a therapeutic manner, requiring trust and sensitivity to help the client recognize inconsistencies in thoughts or behaviors.
A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
- A. Hematocrit 42%
- B. Urine specific gravity 1.022
- C. BUN 28 mg/dL
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: BUN 28 mg/dL. An elevated BUN level indicates poor protein metabolism, which could be a sign that the current enteral formula is not being adequately utilized by the client. This could lead to malnutrition or other complications.
A: Hematocrit measures the volume percentage of red blood cells in blood. It is not directly related to enteral feedings.
B: Urine specific gravity reflects hydration status and kidney function, not related to enteral feedings.
D: Sodium level is not specific to enteral feedings.
In summary, an elevated BUN level signifies poor protein metabolism and indicates a need for a change in the enteral formula to better meet the client's nutritional needs.
A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following responses should the nurse make?
- A. Reassure the client that the provider will use advanced medical knowledge to treat any further problems with her tumor.
- B. Sit quietly with the client and follow her cues.
- C. Suggest that the client discuss her fears with the provider.
- D. Gently change the subject to something more positive.
Correct Answer: B
Rationale: Providing silent support and allowing the client to express emotions promotes emotional well-being.