a nurse is caring for a client with a pressure ulcer which of the following interventions is most appropriate
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1. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

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 patient is being educated about a clear liquid diet. Which of the following should the nurse instruct the patient to avoid?

Correct answer: D

Rationale: The correct answer is D: Orange sherbet. A clear liquid diet consists of liquids that are transparent and easily digestible. Orange sherbet, being a frozen dessert, is not a clear liquid and should be avoided. Choices A, B, and C are all acceptable in a clear liquid diet. Lemon-lime sports drinks, ginger ale, and black coffee are clear liquids that can be included in the diet as they are transparent and leave little residue in the gastrointestinal tract, unlike orange sherbet.

3. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

4. How should a healthcare provider manage a patient with hypertensive crisis?

Correct answer: A

Rationale: In a hypertensive crisis, the immediate goal is to lower blood pressure to prevent organ damage. Administering antihypertensive medications helps achieve this goal efficiently. Monitoring blood pressure is essential to assess the effectiveness of the treatment and adjust medication as needed. Providing a high-sodium diet and fluid restriction (Choice B) can exacerbate hypertension by increasing blood pressure. Diuretics and oxygen therapy (Choice C) are not the first-line treatment for hypertensive crisis, as the priority is rapid blood pressure reduction. Providing IV fluids and monitoring for kidney failure (Choice D) are not primary interventions for managing hypertensive crisis; the focus is on blood pressure control and organ protection.

5. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?

Correct answer: B

Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.

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