Nursing Elites

1. In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. A deep pocket of infection and necrotic tissues.
• C. An area of erythema that is painful to touch.
• D. Visible subcutaneous tissue with sloughing.

Correct answer: A

Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.

2. A client who has undergone abdominal surgery calls the nurse and reports that she just felt 'something give way' in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately:

• A. Contacts the physician
• B. Documents the findings
• C. Places the client in a supine position with the legs flat
• D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution

Correct answer: D

Rationale: In the scenario described, the presence of wound dehiscence indicates a separation of the layers of the surgical incision. The immediate priority for the nurse is to cover the abdominal wound with a sterile dressing moistened with sterile saline solution. This helps to protect the wound from contamination and promotes a moist environment conducive to healing. Contacting the physician (Choice A) is important, but the initial action should be to address the wound. Documenting the findings (Choice B) is necessary but not the immediate priority. Placing the client in a supine position with the legs flat (Choice C) is not indicated in this situation as wound dehiscence requires wound care intervention.

3. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first?

• A. Notify the healthcare provider of the finding immediately.
• B. Complete a neurovascular assessment of the right hand.
• C. Elevate the client's right hand on one or two pillows.
• D. Measure the client's blood pressure and apical pulse rate.

Correct answer: B

Rationale: Completing a neurovascular assessment of the right hand is the priority in this situation. This assessment will help determine the circulation, sensation, and movement of the affected limb, ensuring there are no complications like compartment syndrome or impaired perfusion. Notifying the healthcare provider immediately (Choice A) might be necessary but should come after assessing the client's neurovascular status. Elevating the client's right hand (Choice C) can be helpful in some cases but should not precede a neurovascular assessment. Measuring the client's blood pressure and apical pulse rate (Choice D) is important but not the priority when assessing a potential vascular compromise in the limb.

4. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

• A. The tube is patent
• B. There is probably a kink in the tubing
• C. Suction should be added to the system
• D. The client is retaining airway secretions

Correct answer: A

Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.

5. The nurse is teaching a patient who will be discharged home from the hospital to take amoxicillin (Amoxil) twice daily for 10 days. Which statement by the nurse is correct?

• A. Discontinue the antibiotic when your temperature returns to normal and your symptoms have improved.
• B. If diarrhea occurs, stop taking the drug immediately and contact your provider.
• C. Stop taking the drug and notify your provider if you develop a rash while taking this drug.
• D. You may save any unused antibiotic to use if your symptoms recur.

Correct answer: C

Rationale: Patients who develop signs of allergy, such as rash, should notify their provider before continuing medication therapy. Patients should be counseled to continue taking their antibiotics until completion of the prescribed regimen even when they feel well. Diarrhea is an adverse effect but does not warrant cessation of the drug. Before deciding to stop taking a medication due to a side effect, encourage the patient to contact the provider first. Patients should discard any unused antibiotic.

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