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Which of the following characteristics would put a client at the greatest risk for impaired wound healing after abdominal surgery?
- A. Age 75 years.
- B. Age 30 years, with poorly controlled diabetes.
- C. Age 55 years, with myocardial infarction.
- D. Age 60 years, with peripheral vascular disease.
Correct Answer: B
Rationale: Poorly controlled diabetes impairs wound healing due to high glucose levels affecting immune response and tissue repair, posing a greater risk than age or other conditions listed.
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What should the nurse teach a client with Parkinson's about fall prevention?
- A. Use a walker if unsteady.
- B. Avoid all physical activity.
- C. Wear tight shoes.
- D. Keep lights dimmed.
Correct Answer: A
Rationale: Using a walker if unsteady helps prevent falls in Parkinson's patients with gait instability.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.
The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? Select all that apply.
- A. Purchase sunscreen containing benzophenoness to check UVA and UVB rays.
- B. Use sunscreen with a minimum of 15 sun protection factor (SPF).
- C. Obtain genetic screening to identify risk of melanoma.
- D. Apply sunscreen only on sunny days, especially between 10 AM and 2 PM.
- E. Have a pigmented lesion biopsied by shaving if it looks suspicious.
- F. Rub baby oil to lubricate skin before going out in the sun.
Correct Answer: A,B
Rationale: Sunscreen with benzophenones and SPF 15 or higher protects against UVA/UVB rays. Genetic screening is not routine, sunscreen should be used daily, shave biopsies are inappropriate, and baby oil increases UV damage.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
- A. Provide essential fatty acids.
- B. Provides extra carbohydrates.
- C. Promotes effective metabolism of glucose.
- D. Maintains a normal body weight.
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
The nurse is preparing a staff education program about medication reconciliation. Which of the following information should the nurse include? Select all that apply.
- A. Discontinued medications should be included while performing medication reconciliation.
- B. Medications taken on an as-needed basis can be excluded from this process.
- C. New medication orders should be compared with the current list.
- D. Medication reconciliation should be performed after the client has been discharged.
- E. Over-the-counter (OTC) medications should be included in the medication reconciliation.
Correct Answer: A,C,E
Rationale: Medication reconciliation includes discontinued medications, new orders, and OTC medications to ensure a complete and accurate list; it should occur at admission, transfer, and discharge, and PRN medications should not be excluded.