Nokea
A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.
You may also like to solve these questions
A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?
- A. To allow full extension of the hip and knee joints
- B. To prevent aspiration problems
- C. To promote lung expansion
- D. To prevent abdominal distention
Correct Answer: B
Rationale: The correct answer is B: To prevent aspiration problems. When a client is lying on their side, it helps prevent the pooling of secretions in the back of the throat, reducing the risk of aspiration. This is crucial for unconscious clients who may have difficulty protecting their airway.
Choice A is incorrect because lying on the side does not specifically relate to the extension of hip and knee joints. Choice C is incorrect as lying on the side does not directly promote lung expansion. Choice D is incorrect as lying on the side does not prevent abdominal distention.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate and reliable measurement of the heart rate, especially in clients taking cardiovascular medications where variations may occur. Checking for a full minute allows the nurse to capture any irregularities or changes in the pulse rhythm.
Choice B is incorrect because using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, is used to listen to the apical pulse for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the skin can distort the sound of the pulse.