a client is admitted with a stage four pressure ulcer that has a black hardened surface and a light pink wound bed with a malodorous green drainage wh
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Nursing Elites

HESI RN

HESI Fundamentals

1. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?

Correct answer: C

Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.

2. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?

Correct answer: C

Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.

3. What action should be taken when adding sterile liquids to a sterile field?

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

4. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

Correct answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

5. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?

Correct answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.

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