Nursing Elites

1. The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?

• A. Lightly coat the wound with povidone-iodine solution
• B. Irrigate the wound with sterile normal saline
• C. Flush the wound with sterile hydrogen peroxide
• D. Remove the eschar with a wet-to-dry dressing

Correct answer: B

Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.

2. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

• A. Document the client’s temperature fluctuations
• B. Assess for flushed, warm skin consistently
• C. Measure temperature at regular intervals
• D. Use different sites for temperature measurement

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

3. A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?

• A. Arterial blood gases (ABGs)
• B. Complete blood count (CBC)
• C. Blood glucose levels
• D. Serum electrolyte levels

Correct answer: A

Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.

4. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

• A. Complete blood count (CBC)
• B. Serum potassium level
• C. Liver function tests (LFTs)
• D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

5. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

• A. Document that the client responds to a painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the healthcare provider.

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

Similar Questions