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A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?
- A. Prepare the sterile dressing supplies 30 min before the dressing change.
- B. Don sterile gloves before removing the dressing,
- C. Disinfect the wound bed with alcohol before applying tape.
- D. Offer the client pain medication before the procedure.
Correct Answer: D
Rationale: Offering pain medication beforehand reduces discomfort during the dressing change for a stage III ulcer. Supplies should be prepared just before, sterile gloves are used after removal, and alcohol isn't used on open wounds.
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48
A nurse is reinforcing bladder management instructions with a client who has urinary incontinence. Which of the following statements by the client indicates an understanding?
- A. I should use the bathroom at set times during the day.
- B. I can continue to drink coffee every day.
- C. I can insert a catheter in my bladder at bedtime.
- D. I should stop drinking fluids an hour before bedtime.
- E. I'll avoid pelvic floor exercises.
- F. I can drink alcohol freely.
- G. I should ignore urges to urinate.
Correct Answer: A
Rationale: Scheduled voiding helps manage incontinence; coffee and alcohol worsen it, and self-catheterization isn't routine.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect hidden blood in stool, often for colorectal cancer screening, but false positives can skew results. Ibuprofen, an NSAID, irritates the gastric mucosa, causing microbleeding that may appear in stool, unrelated to colonic sources. Citrus juice doesn't affect heme detection vitamin C may cause false negatives, not positives, and 3 days prior minimizes impact. A hemorrhoidectomy 1 year ago is healed, unlikely to bleed now unless complications persist, which isn't suggested. Breast cancer history doesn't influence gastrointestinal bleeding unless metastatic, an unlikely scenario here. Ibuprofen's known GI side effects align with testing guidelines (e.g., avoiding NSAIDs pre-test), making it the most likely false-positive trigger, requiring the nurse to clarify timing and adjust interpretation.
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the partner indicates an understanding of the teaching?
- A. I can take my partner outside of the room as long as they wear a mask.
- B. I will wash my hands as soon as I leave the room.
- C. I will wear a gown when I help my partner take a bath.
- D. I will reuse unsoiled gloves when I re-enter the room.
Correct Answer: B
Rationale: Hand washing upon leaving prevents MRSA spread, a key contact precaution. Masks don't suffice, gowns are needed for bathing, and gloves must be fresh each entry.
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. LDL
- B. INR
- C. BUN
- D. Hct
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.
VITAL SIGNS
Day 1:
TEMPERATURE 36° C (96.8° F)
BLOOD PRESSURE 140/80 mm Hg
HEART RATE 98/min
RESPIRATORY RATE 24/min
OXYGEN SATURATION 97% on room air
Day 2, 0800:
TEMPERATURE 37° C (98.6° F)
BLOOD PRESSURE 122/60 mm Hg
HEART RATE 85/min
RESPIRATORY RATE 18/min
OXYGEN SATURATION 98% on room air
Day 2, 1600:
Findings
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Acute compartment syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Infection
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Fat embolism syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. Which finding is consistent with acute compartment syndrome?
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer: A, C
Rationale: Acute compartment syndrome post-ORIF arises from pressure buildup in muscle compartments, impairing perfusion. Increased pain at the incision site severe, unrelieved by analgesics, and disproportionate to the procedure is a hallmark, reflecting nerve and tissue ischemia. Dyspnea suggests fat embolism syndrome, a separate complication from marrow release, not compartment pressure. Tingling indicates nerve compression, a later sign, but pain precedes it in the 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). Swelling occurs, but pain's intensity and persistence distinguish compartment syndrome from normal postoperative edema. Early recognition of escalating pain prompts fasciotomy, preventing necrosis, making it the most consistent finding per orthopedic emergency protocols.