Nokea
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?
- A. Vitamin C
- B. Iron
- C. Potassium
- D. Niacin
Correct Answer: A
Rationale: Vitamin C is essential for collagen synthesis and wound healing. It helps improve the strength of the wound and promotes tissue repair, making it crucial for clients healing by secondary intention.
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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 contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
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.