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A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.
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UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?
- A. A feeding is infusing at 40 mL/hr through an enteral feeding tube
- B. The urine meter attached to the urinary drainage bag is completely full
- C. There is a large dependent loop in the client's urinary drainage tubing
- D. Purulent drainage is present around the insertion site of the feeding tube
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What action should be taken when adding sterile liquids to a sterile field?
- A. Use an expired sterile liquid if the bottle is sealed and unopened.
- B. Consider the sterile field contaminated if it becomes wet during the procedure.
- C. Remove the container cap and place it with the inside facing up on the sterile field.
- D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.
Correct Answer: B
Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.
The client has a chest tube. What is the most important action for the nurse to take?
- A. Ensure the chest tube remains unclamped at all times.
- B. Empty the chest tube every 2 hours.
- C. Keep the drainage system below the level of the chest.
- D. Assess for subcutaneous emphysema.
Correct Answer: C
Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct Answer: B
Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.
At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Leave the room and close the door to the client's room
- B. Assess the appearance of the client's surgical dressing
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Discuss symptoms of sleep deprivation with the client
Correct Answer: A
Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.