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1. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?
- A. Administer a protein supplement
- B. Increase protein intake in the client's diet
- C. Increase IV fluid intake to improve hydration
- D. Cleanse the wound from the center outwards
Correct answer: D
Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.
2. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid drinking water before meals
- B. I might experience hair loss during treatment
- C. I might experience an increase in appetite
- D. I should expect my appetite to increase
Correct answer: B
Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.
3. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?
- A. Muscle weakness
- B. Nausea
- C. Increased thirst
- D. Restlessness
Correct answer: A
Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.
4. What should a healthcare provider prioritize for a client diagnosed with bipolar disorder?
- A. Monitor for hyperactivity
- B. Monitor for signs of depression
- C. Monitor for changes in self-esteem
- D. Monitor for changes in energy levels
Correct answer: B
Rationale: When caring for a client diagnosed with bipolar disorder, the priority is to monitor for signs of depression. Individuals with bipolar disorder are at risk of severe depressive episodes, making it crucial to watch for signs of depression. While changes in energy levels and self-esteem are common in bipolar disorder, they are not the primary focus. Hyperactivity is a characteristic of the manic phase of bipolar disorder, so monitoring for depression is the priority in this case.
5. How should a healthcare professional care for a patient with a colostomy?
- A. Empty the colostomy bag regularly
- B. Provide a high-fiber diet
- C. Monitor for signs of infection
- D. Change the colostomy bag every 3 days
Correct answer: A
Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.
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