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A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
- A. Apply a heat lamp twice a day
- B. Cleanse with 0.9% sodium chloride irrigation
- C. Cleanse with povidone-iodine solution
- D. Massage reddened areas during dressing changes
Correct Answer: B
Rationale: 0.9% sodium chloride irrigation is recommended for granulating tissue. Povidone-iodine is cytotoxic and should not be used. Heat lamps and massage can cause further tissue damage.
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A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect?
- A. Ability to perform oral hygiene
- B. Ability to bathe himself
- C. Ability to identify how often he should schedule his car for an oil change
- D. Ability to balance his bank account
- E. Ability to dress himself
Correct Answer: A,B,E
Rationale: Assessing ADLs includes evaluating self-care abilities like hygiene, bathing, and dressing.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop gross motor skills around 2 years old, making riding a tricycle a suitable activity. Jumping rope (choice A) requires more advanced coordination and balance. Printing letters and numbers (choice C) involves fine motor skills that develop later. Using scissors (choice D) also requires more advanced fine motor skills.
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, 'something popped in my belly.' The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?
- A. Position the client supine with his hips and knees bent.
- B. Prepare to administer an IV infusion of 0.9% sodium chloride.
- C. Cover the wound with moist sterile gauze.
- D. Measure the client's vital signs.
Correct Answer: C
Rationale: Evisceration requires immediate covering of the wound with a sterile, moist dressing to prevent infection and tissue damage.
A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.