Nokea
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
- A. infected.
- B. not healing.
- C. necrotic.
- D. healing.
Correct Answer: D
Rationale: The wound is not infected. An infected wound would contain pus, debris, and exudate. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries.
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Why should a nurse practice caution when changing the wound dressings of a client who underwent surgery?
- A. To avoid damaging new tissue.
- B. To avoid causing pain to the client.
- C. To fasten the wound healing.
- D. To avoid wound infection.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When teaching a patient to care for himself before discharge, what should the nurse initially do?
- A. Develop a 1-hour teaching session
- B. Give the patient a booklet to read
- C. Prioritize teaching needs
- D. Select specific teaching techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Sneezing and wheezing
- C. Swaying, losing balance or arm drifting
- D. Excessive cerumen in the outer ear
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision?
- A. Administer Kayexalate 15 g orally
- B. Administer spironolactone 25 mg orally
- C. Assess ECG strip for tall T waves
- D. Administer potassium 10 mEq orally
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What should the nurse closely monitor for in a client who has undergone surgery for otosclerosis?
- A. Hypotension
- B. Nausea and vomiting
- C. Decreased urine output
- D. Abnormal facial nerve function
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.