Nokea
The nurse notes that a client’s wound has not improved despite consistent wound care as outlined in the care plan. What should the nurse do next?
- A. Reassess the wound and client’s condition.
- B. Discontinue the current care plan.
- C. Increase the frequency of wound dressing changes.
- D. Refer the client to a specialist immediately.
Correct Answer: A
Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement.
Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing.
Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice.
Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care.
Summary:
Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.
You may also like to solve these questions
After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: A
Rationale: The correct answer is A: 30 minutes before breakfast. Glyburide is a sulfonylurea medication that stimulates insulin release from the pancreas, enhancing glucose uptake. Taking it before breakfast ensures peak insulin levels coincide with the postprandial glucose spike, aiding in glucose control throughout the day. Option B is incorrect as taking it after dinner may lead to hypoglycemia during sleep. Option C is incorrect as midmorning is not an optimal time for a sulfonylurea dose. Option D is incorrect as taking it at bedtime may also increase the risk of hypoglycemia overnight.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: A
Rationale: The correct answer is A because decorticate posturing is characterized by flexion of both upper and lower extremities. This occurs due to damage to the cerebral hemispheres, resulting in abnormal muscle contractions. Choice B describes decerebrate posturing, which is associated with extension of elbows and knees. Choice C is incorrect as it describes abnormal posturing seen in other conditions. Choice D is also incorrect as it describes a different type of abnormal posturing.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
Following the American Cancer Society guidelines, the nurse should recommend that the women:
- A. Perform breast self-examination annually
- B. Have a mammogram annually
- C. Have a normal receptor assay annually
- D. Have a physician conduct a clinical examination every 2 years
Correct Answer: B
Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment.
A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates.
C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society.
D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used.
Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly.
Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride.
Summary:
- Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration.
- Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride.
- Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.