Nokea
A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?
- A. Inflammation
- B. Remodeling phase
- C. Maturation
- D. Proliferation
Correct Answer: A
Rationale: Inflammation is the first phase of wound healing, initiating hemostasis and infection prevention.
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A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Insufficient fiber causes constipation by reducing bowel movement frequency.
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
- A. Flush the tube with sterile sodium chloride solution every 2 hr.
- B. Change the feeding bag every 24 hr.
- C. Position the head of the client's bed at 15°.
- D. Check the gastric residual every 8 hr.
Correct Answer: B
Rationale: Changing the feeding bag every 24 hours prevents bacterial growth and infection, a standard practice for continuous feedings.
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.
A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?
- A. BMI of 20
- B. Peripheral neuropathy
- C. Immobility
- D. Hypoperfusion
- E. Prealbumin level of 16 mg/dL
Correct Answer: B,C,D,E
Rationale: B: Neuropathy reduces sensation. C: Immobility causes prolonged pressure. D: Hypoperfusion impairs tissue oxygenation. E: Low prealbumin indicates poor nutrition.
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Thirst indicates hyperglycemia as the body attempts to excrete excess glucose, causing dehydration.