Nokea
A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
- A. Apply a heat lamp twice a day
- B. Cleanse with 0.9% sodium chloride irrigation
- C. Cleanse with povidone-iodine solution
- D. Massage reddened areas during dressing changes
Correct Answer: B
Rationale: 0.9% sodium chloride irrigation is recommended for granulating tissue. Povidone-iodine is cytotoxic and should not be used. Heat lamps and massage can cause further tissue damage.
You may also like to solve these questions
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.
A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence?
- A. Gender
- B. Culture
- C. Allergies
- D. Dexterity
- E. Motivation
Correct Answer: B,D,E
Rationale: Cultural beliefs, dexterity limitations, and motivation significantly impact adherence to diabetes management.
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
- A. Assist the client back into bed and apply restraints.
- B. Call the family and ask them to make arrangements for someone to sit with the client.
- C. Check the client for injuries.
- D. Obtain a prescription for medication to sedate the client.
Correct Answer: C
Rationale: The correct answer is C: Check the client for injuries. This is the most appropriate action as it ensures the client's safety and well-being. By checking for injuries, the nurse can assess the extent of harm and provide necessary medical attention promptly. It also helps in determining if further interventions are required.
Choice A is incorrect because restraints should not be applied without proper assessment. Choice B is incorrect as the priority is to address the immediate physical needs of the client. Choice D is incorrect as sedation should not be the first response to a fall.