Nokea
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
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The nurse is caring for a client with a chest tube. Which finding indicates a potential complication?
- A. Continuous bubbling in the water seal chamber.
- B. Fluctuation in the water seal with breathing.
- C. Serosanguineous drainage.
- D. Pain at the insertion site.
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate attention.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted to the hospital outpatient clinic for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
- A. Red blood cell count.
- B. Direct and indirect bilirubin levels.
- C. Reticulocyte count.
- D. Albumin level.
Correct Answer: D
Rationale: Albumin levels reflect nutritional status, as low levels indicate protein malnutrition, common in cancer patients. The other tests assess hematologic or liver function.
A client with pneumonia is receiving oxygen therapy. The nurse notes cyanosis and a respiratory rate of 32 breaths/min. What should the nurse do first?
- A. Increase the oxygen flow rate.
- B. Notify the physician.
- C. Encourage coughing and deep breathing.
- D. Reposition the client.
Correct Answer: B
Rationale: Cyanosis and tachypnea indicate worsening hypoxia, requiring immediate physician notification to adjust treatment.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about medication management. Which of the following medications should the client expect to take?
- A. Methotrexate.
- B. Colchicine.
- C. Allopurinol.
- D. Probenecid.
Correct Answer: A
Rationale: Methotrexate is a disease-modifying antirheumatic drug (DMARD) commonly used for rheumatoid arthritis.
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.