Nokea
After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching?
- A. Low-fat diet with whole grains and cereals and vitamin supplements
- B. High-protein diet with vitamins and mineral supplements
- C. Vegetarian diet with nutritional supplements and fish oil capsules
- D. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
Correct Answer: B
Rationale: The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.
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A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?
- A. Recent wound assessment, including size and appearance
- B. Insurance information for billing and coding purposes
- C. Complete health history and physical assessment findings
- D. Resources available to the client for wound care supplies
Correct Answer: A
Rationale: The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
A nurse evaluates the following data in a clients chart: 66-year-old male with a health history of cerebral vascular accident and left-side paralysis, white blood cell count: 8000/mm^3, prealbumin: 15.2 mg/dL, albumin: 4.2 g/dL, lymphocyte count: 2000/mm^3, sacral ulcer 4 cm x 2 cm x 1.5 cm. Based on this information, which action should the nurse take?
- A. Consult a dietitian to increase nutritional intake.
- B. Apply a transparent film dressing to the ulcer.
- C. Reposition the client every 4 hours.
- D. Administer antibiotics for wound infection.
Correct Answer: A
Rationale: The prealbumin level of 15.2 mg/dL is low (normal range is typically 15"?36 mg/dL), indicating potential malnutrition, which can impair wound healing. Consulting a dietitian to optimize nutritional intake is the priority to support tissue repair. The white blood cell count is normal, so antibiotics are not indicated. Transparent film dressings are not suitable for deep ulcers, and repositioning should occur more frequently than every 4 hours.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?
- A. Client with blood cultures pending
- B. Client who has thin, serous wound drainage
- C. Client with a white blood cell count of 23,000/mm^3
- D. Client transferred from intensive care with an elevated white blood cell count
Correct Answer: C
Rationale: An elevated white blood cell count, such as 23,000/mm^3, indicates a potential infection. The nurse should evaluate this client for signs of a wound infection, as an elevated white blood cell count is a strong indicator of an infectious process.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
- A. A 44-year-old prescribed IV antibiotics for pneumonia
- B. A 26-year-old who is bedridden with a fractured leg
- C. A 65-year-old with hemiplegia and incontinence
- D. A 78-year-old requiring assistance to ambulate with a walker
Correct Answer: C
Rationale: Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client?
- A. Punch skin biopsy
- B. Viral cultures
- C. Wood's lamp examination
- D. Diascopy
Correct Answer: A
Rationale: This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates polymorph making skin lesions easier to examine.