Nokea
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.
You may also like to solve these questions
The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client's right to emergency services, regardless of ability to pay, is provided by which piece of legislation?
- A. HIPAA
- B. the Continuity of Care Act
- C. the Patient's Bill of Rights
- D. the Code of Ethics for Nurses
Correct Answer: D
Rationale: The Emergency Medical Treatment and Active Labor Act (EMTALA) ensures that emergency services are provided regardless of ability to pay, not the options listed.
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The nurse is caring for a client with leukemia who has received the drug (daunorubicin) Cerubidine. Which of the following common side effects would cause the most concern?
- A. Nausea
- B. Vomiting
- C. Cardiotoxicity
- D. Alopecia
Correct Answer: C
Rationale: Daunorubicin is known for cardiotoxicity, which can lead to heart failure and is life-threatening, making it the most concerning side effect. Nausea, vomiting, and alopecia are common but less severe.