a nurse is planning to irrigate and dress a clean granulating wound for a client which of the following actions should the nurse take
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

2. How should a healthcare provider assess and manage a patient with a suspected urinary tract infection (UTI)?

Correct answer: A

Rationale: When assessing and managing a patient with a suspected UTI, the priority is to start antibiotic therapy to treat the infection. Antibiotics are crucial in eliminating the bacteria causing the UTI. While hydration is important to help flush out the bacteria, pain management can help alleviate discomfort but is not the primary treatment. Patient education is vital for prevention and management but is not the immediate intervention required for a suspected UTI.

3. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

4. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?

Correct answer: B

Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.

5. A client with hypokalemia is commonly expected to present with which of the following findings?

Correct answer: A

Rationale: The correct answer is A: Muscle weakness. Hypokalemia is characterized by low potassium levels in the blood, which can lead to muscle weakness. This occurs because potassium is essential for proper muscle function, and a deficiency can impair muscle strength. Nausea (choice B) is not a typical finding associated with hypokalemia. Tingling sensation (choice C) is more commonly linked to issues like nerve damage or poor blood circulation, rather than hypokalemia. Increased thirst (choice D) is not a direct symptom of hypokalemia; it is more commonly seen in conditions like diabetes or dehydration.

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