a nurse is caring for a client who has a prescription for wound irrigation which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

2. A client has a new diagnosis of nephrotic syndrome, and the nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?

Correct answer: B

Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.

3. Following a total hip arthroplasty, what intervention should the healthcare provider implement for the client?

Correct answer: A

Rationale: Placing a pillow between the client's legs is crucial post hip arthroplasty surgery to prevent hip dislocation. This intervention helps maintain proper alignment and prevents legs from crossing midline, reducing the risk of hip prosthesis dislocation. Elevating the head of the bed to 45 degrees, positioning the client on the operative side, or keeping the client's legs adducted are not recommended postoperative interventions for a total hip arthroplasty, as they can increase the risk of complications and compromise the surgical site.

4. During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.

5. A healthcare provider is planning care for a client who has a latex allergy. Which of the following actions should the healthcare provider include in the plan?

Correct answer: B

Rationale: Placing a sign on the client’s door is crucial in alerting healthcare providers to the client's latex allergy, helping them avoid using latex products, which can trigger an allergic reaction. This precaution can prevent accidental exposure and ensure the client's safety during care. Choices A, C, and D are incorrect. Using latex gloves without powder (Choice A) is a good practice, but the question is specifically asking about an action related to the client's latex allergy, not the healthcare provider's protection. Applying latex gloves before donning gloves (Choice C) is unnecessary and could exacerbate the client's latex allergy. Avoiding using plastic equipment (Choice D) is not related to preventing exposure to latex, which is the primary concern in this scenario.

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