Nokea
The nurse has documented the following wound assessment. "Shallow, open,
reddened ulcer with no slough on the anterior region of the right heel?"? what
stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct Answer: D
Rationale:
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A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct Answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
Most adults with human immunodeficiency virus will exhibit which of the
following laboratory values?
- A. Higher than normal number of CD4+ T-cells and CD8+ T-cells are normal
- B. Lower than normal number of CD4+ T-cells and higher than normal CD8+ T-cells
- C. Higher than normal number of CD4+ T-cells and CD8+ T-cells are low
- D. Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal
Correct Answer: D
Rationale:
A nurse is caring for a client who has methicillin-resistant Staphylococcus
aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room
to check the client's pulse. What personal protective equipment (PPE) should
the nurse don?
- A. PAPR mask
- B. Sterile gloves
- C. Gown
- D. Surgical mask
Correct Answer: C
Rationale:
Which of the following clients should be placed in isolation for airborne
precautions?
- A. A high school wrestling championship with a rash
- B. A client that recently travelled and developed a fever with cough
- C. A client with an unknown skin infection
- D. A client with heart palpitations
Correct Answer: B
Rationale:
A client has an open wound with creamy thick yellow drainage. How would the
nurse document this finding?
- A. Purulent
- B. Serosanguinous
- C. Sanguineous
- D. Serous
Correct Answer: A
Rationale: