Nokea
What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?
- A. Apply hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Elevate the affected area
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.
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A patient is receiving radiation therapy. Which of the following skin care instructions should the nurse provide?
- A. Apply a heating pad to the radiation site.
- B. Use scented lotions to moisturize the skin.
- C. Keep the radiation site covered with a bandage.
- D. Wear loose clothing over the radiation site.
Correct Answer: D
Rationale: Correct Answer: The nurse should instruct the patient to wear loose clothing over the radiation site. This helps prevent skin irritation and promotes healing by reducing friction and irritation on the treated area.\nChoice A is incorrect because applying a heating pad can further irritate the skin that is already sensitive due to radiation therapy.\nChoice B is incorrect because scented lotions may contain ingredients that could further irritate the skin.\nChoice C is incorrect because covering the radiation site with a bandage can trap moisture and lead to skin breakdown, increasing the risk of infection.
A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. 1+ pitting edema in the lower extremities
- C. Weight gain of 2.3 kg (5 lb) in 1 week
- D. Mild headache
Correct Answer: C
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.
When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will stop taking my medication once my blood pressure is within normal range.
- D. I will sit quietly for 5 minutes before measuring my blood pressure.
Correct Answer: D
Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.
Which electrolyte imbalance is most common in patients receiving furosemide?
- A. Hypokalemia
- B. Hypercalcemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A, Hypokalemia. Furosemide, a loop diuretic, commonly leads to potassium loss in the urine, causing hypokalemia. This electrolyte imbalance should be closely monitored in patients taking furosemide. Choices B, C, and D are incorrect because hypercalcemia, hyponatremia, and hyperkalemia are not typically associated with furosemide use.
Which electrolyte imbalance is a common concern in patients receiving loop diuretics?
- A. Hyperkalemia
- B. Hyponatremia
- C. Hypokalemia
- D. Hypercalcemia
Correct Answer: C
Rationale: The correct answer is Hypokalemia (Choice C). Loop diuretics can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is a common concern with loop diuretic therapy and necessitates regular monitoring. Hyperkalemia (Choice A) is not typically associated with loop diuretics but with conditions like renal failure. Hyponatremia (Choice B) is more common with thiazide diuretics. Hypercalcemia (Choice D) is not a typical concern with loop diuretic use.