a nurse is reviewing the medical records of a client who has a pressure ulcer which of the following is an expected finding
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1. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

Correct answer: A

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.

2. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

3. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

4. How should a healthcare provider manage a patient with a fever?

Correct answer: A

Rationale: When managing a patient with a fever, the appropriate approach involves administering antipyretics to reduce the fever and monitoring the patient's vital signs to assess their response to treatment. Administering antipyretics helps to lower the body temperature and manage fever symptoms effectively. Monitoring vital signs is crucial to ensure the patient's condition is improving. Providing cold compresses, as mentioned in choice B, can help in managing fever symptoms, but it does not address the root cause of the fever. Encouraging the patient to rest, as stated in choice C, is beneficial for recovery, but increasing fluid intake is essential to prevent dehydration. Restricting fluid intake and providing bed rest, as in choice D, can lead to dehydration and hinder the body's ability to fight off the infection causing the fever. Therefore, the best course of action for a healthcare provider is to administer antipyretics while closely monitoring the patient's vital signs.

5. What are the key nursing interventions for a patient undergoing dialysis?

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

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