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During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?
- A. Stringy, white tissue
- B. Translucent, red tissue
- C. Soft, yellow tissue
- D. Thick, black tissue
Correct Answer: B
Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.
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A healthcare professional is explaining the use of written consent forms to a newly-licensed healthcare professional. The healthcare professional should ensure that a written consent form has been signed by which of the following clients?
- A. A client who has a prescription for a transfusion of packed red blood cells.
- B. A client who is scheduled for a routine physical examination.
- C. A client who is undergoing a minor surgical procedure without anesthesia.
- D. A client who has been prescribed a new medication.
Correct Answer: A
Rationale: Correct! Written consent is required for procedures that carry significant risks, such as blood transfusions, to ensure the client's informed consent and understanding of the procedure. In this case, a transfusion of packed red blood cells is an invasive procedure that carries risks, making it essential to have the client's written consent. Choices B, C, and D do not typically require written consent as routine physical examinations, minor surgical procedures without anesthesia, and new medication prescriptions do not carry the same level of risk and complexity as a blood transfusion.
A client with difficulty self-feeding due to rheumatoid arthritis should be referred to which member of the interprofessional care team to use adaptive devices?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D, Occupational therapist. Occupational therapists specialize in assisting clients with adaptive devices to enhance their ability to perform daily activities like self-feeding. They evaluate client needs and provide interventions to promote independence in activities of daily living. Choice A, Social worker, focuses on psychosocial support and community resources, not directly addressing the physical aspect of self-feeding difficulty. Choice B, Certified nursing assistant, is involved in direct patient care but lacks specialized training in adaptive devices. Choice C, Registered dietitian, primarily focuses on nutrition-related issues and may not have the expertise in adaptive devices and functional rehabilitation necessary for this client's self-feeding challenges.
A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?
- A. Administer oxygen via a nasal cannula.
- B. Measure the client's vital signs.
- C. Obtain a 12-lead ECG.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: A
Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.
When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?
- A. I can concentrate best in the morning.
- B. I feel anxious about learning the process.
- C. I have a lot of questions about insulin.
- D. I am not sure if I can manage this at home.
Correct Answer: A
Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.
A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?
- A. Cold extremities
- B. Increased appetite
- C. Elevated blood pressure
- D. Increased level of consciousness
Correct Answer: A
Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.