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While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?
- A. Determine if the drainage has an unpleasant odor.
- B. Monitor the client's white blood cell count (WBC).
- C. Request a culture and sensitivity of the wound.
- D. Cleanse the wound with a sterile saline solution.
Correct Answer: C
Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.
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The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?
- A. Inform the UAP that suction is available at the bedside.
- B. Instruct the UAP to notify the nurse if the client chokes.
- C. Observe the UAP's ability to implement precautions during feeding.
- D. Ask the UAP about previous experience in performing this skill.
Correct Answer: C
Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.
A healthcare provider is conducting a health education session about the prevention of type 2 diabetes. What lifestyle modification should be emphasized?
- A. Increasing physical activity
- B. Reducing dietary sugar intake
- C. Regular health screenings
- D. All of the above
Correct Answer: D
Rationale: To effectively prevent type 2 diabetes, individuals should focus on a combination of lifestyle modifications. Increasing physical activity helps maintain a healthy weight and improves insulin sensitivity. Reducing dietary sugar intake can lower the risk of developing diabetes by managing blood sugar levels. Regular health screenings are crucial for early detection and timely intervention. Emphasizing all these modifications together provides a comprehensive approach to diabetes prevention. Choices A, B, and C are all important components of a healthy lifestyle that can contribute to reducing the risk of type 2 diabetes.
A client is prescribed metformin for the management of type 2 diabetes. What is the primary action of this medication?
- A. Stimulates insulin secretion from the pancreas.
- B. Increases insulin sensitivity in various tissues.
- C. Decreases hepatic glucose production.
- D. Delays absorption of glucose from the intestines.
Correct Answer: C
Rationale: The correct answer is C: Decreases hepatic glucose production. Metformin primarily works by reducing the production of glucose in the liver (hepatic glucose production) and by improving insulin sensitivity in various tissues. Choice A is incorrect as metformin does not stimulate insulin secretion from the pancreas. Choice B is incorrect as metformin increases insulin sensitivity in various tissues, not just muscle cells. Choice D is incorrect as metformin does not delay glucose absorption from the intestines.
A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete.
- B. Take all prescribed medications as directed.
- C. Schedule a follow-up appointment with the healthcare provider.
- D. Wear a mask when in public places.
Correct Answer: B
Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.
A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?
- A. Administer an epinephrine injection
- B. Call for immediate medical help
- C. Monitor airway, breathing, and circulation
- D. All of the above
Correct Answer: A
Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.