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The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Apply a hydrocolloidal gel dressing.
- C. Replace the gauze with a transparent dressing.
- D. Increase the frequency of the dressing changes.
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.
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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Paper mask and gown.
- B. A sputum specimen.
- C. The nurse's stethoscope.
- D. Bed linens.
Correct Answer: A
Rationale: Contaminated mask and gown require biohazard disposal.
The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
- A. Use firm pressure to pass the tube through the glottis.
- B. Have the client tilt head backward to open the passage.
- C. Give the client a few sips of water to drink.
- D. Remove the tube and attempt reinsertion.
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
- A. Apply a lubricating lotion to the skin.
- B. Pad all bony prominences.
- C. Encourage a high protein diet.
- D. Bathe with a mild soap daily.
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.