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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury 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. Replace the gauze with a transparent dressing.
- C. Increase the frequency of the dressing changes.
- D. Apply a hydrocolloid gel dressing.
Correct Answer: D
Rationale: Hydrocolloid promotes moist healing.
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The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. C-reactive protein level
- B. Serum potassium and sodium levels
- C. Neutrophil count
- D. Platelet count
Correct Answer: A
Rationale: CRP indicates inflammation, but neutrophils are more specific for infection.
A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement?
- A. Orient the client to their surroundings.
- B. Close the client's room door.
- C. Escort the client back to the room.
- D. Raise the four side rails on the bed.
- E. Secure a bed alarm on the mattress.
Correct Answer: A,C,E
Rationale: Orientation, escort, and alarm ensure safety.
The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.