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A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?
- A. Apply pressure directly to the wound
- B. Remove the dressings to assess the wound
- C. Use a clean dressing over the saturated one
- D. Apply alcohol to the wound
Correct Answer: C
Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.
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A nurse is reviewing the medical records of a group of older adult clients. Which risk factor should the nurse identify as placing older adults at an increased risk for infections?
- A. Improved nutritional status
- B. Increased mobility
- C. Chronic conditions
- D. Lowered immune function
Correct Answer: D
Rationale: The correct answer is D: Lowered immune function. Older adults often experience a decline in immune function as they age, making them more vulnerable to infections. This weakened immune system can result in increased susceptibility to various pathogens. Choice A, 'Improved nutritional status,' is incorrect because good nutrition can actually help support the immune system. Choice B, 'Increased mobility,' is not directly related to an increased risk of infections. Choice C, 'Chronic conditions,' while they can contribute to a weakened immune system, do not directly address the primary risk factor for infections in older adults.
A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?
- A. Use written communication
- B. Speak louder than usual
- C. Face the client when speaking
- D. Provide care in a quiet environment
Correct Answer: A
Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?
- A. Wear non-sterile gloves
- B. Apply sterile gloves over non-sterile gloves
- C. Change gloves if the sterile solution splashes onto the sterile field
- D. Cover the sterile field with a sterile drape
Correct Answer: C
Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.
A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?
- A. Limit sodium intake to 2 grams per day
- B. Increase fluid intake to 2 liters per day
- C. Avoid potassium-rich foods
- D. Avoid alcohol consumption
Correct Answer: B
Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.
A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Increased fluid intake
- D. Use of a special mattress
Correct Answer: B
Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.