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A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?
- A. Erythema on the skin surrounding a client's wound
- B. Deep red color on the center of a client's wound
- C. Increase in serosanguineous exudate from a client's wound
- D. Inflammation noted on the tissue edges of a client's wound
Correct Answer: B
Rationale: The correct answer is B: Deep red color on the center of a client's wound. This finding indicates wound healing as it suggests the formation of granulation tissue, which is essential for the wound healing process. Granulation tissue is rich in blood vessels and appears deep red in color. This indicates that the wound is in the proliferative phase of healing.
Choice A - Erythema on the skin surrounding a client's wound - Erythema typically indicates inflammation and is not a clear sign of wound healing.
Choice C - Increase in serosanguineous exudate from a client's wound - Increased exudate may indicate inflammation or infection, not necessarily healing.
Choice D - Inflammation noted on the tissue edges of a client's wound - Inflammation suggests the wound is still in the inflammatory phase of healing, not the proliferative phase where granulation tissue forms.
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A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take?
- A. Request that the coworker complete an incident report.
- B. File an anonymous report of the incident to the nurse manager.
- C. Identify all witnesses to the incident.
- D. Document a factual account of the incident.
- E. Submit an incident report to the risk manager.
Correct Answer: B,C,D,E
Rationale: Filing an anonymous report, identifying witnesses, documenting the incident, and submitting a report ensure accountability and prevent recurrence without workplace tension.
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
- A. The client's preferred time for bathing
- B. The belief that the client has a difficult relationship with his son
- C. The time the client received his last dose of pain medication
- D. The steps to follow when providing wound care
Correct Answer: C
Rationale: The correct answer is C: The time the client received his last dose of pain medication. This information is crucial for ensuring continuity of care and preventing medication errors. It helps the rehabilitation facility staff know when the next dose is due and if any additional pain relief is needed.
A: The client's preferred time for bathing is important for comfort but not as critical as pain medication timing in a transfer report.
B: The belief about the client's relationship with his son is not relevant to the client's immediate care needs during transfer.
D: The steps for wound care are important but should be included in a separate document or care plan, not necessarily in a brief change-of-shift report.
A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process?
- A. Assess the client's understanding after the provider has talked with her.
- B. Discuss alternative treatment options with the client.
- C. Review the risks and benefits of the procedure with the client.
- D. Place a photocopy of the signed informed consent in the client's medical record.
Correct Answer: A
Rationale: Correct answer: A
Rationale: The nurse's responsibility in the informed consent process is to assess the client's understanding after the provider has discussed the procedure with the client. This step ensures that the client has comprehended the information provided by the provider, clarifies any uncertainties, and confirms the client's voluntary agreement to the procedure. It is crucial for the nurse to confirm the client's understanding to uphold the principles of autonomy and informed decision-making in healthcare.
Summary of other choices:
B: Discussing alternative treatment options is a responsibility of the provider, not the nurse in the informed consent process.
C: Reviewing risks and benefits of the procedure is typically done by the provider during the informed consent process.
D: Placing a photocopy of the signed informed consent in the client's medical record is important but does not directly involve the nurse's role in the informed consent process.
A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.
A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Contact the case manager to discuss discharge options.
- B. Request another family member assist the client's partner with care.
- C. Ask the provider to delay the client's discharge home for a few more days.
- D. Recommend the partner place the client in a long-term care facility.
Correct Answer: A
Rationale: A case manager can explore alternative care options, such as home health or facility placement, to support the client and partner.