what is a key nursing action for a client with a wound infection
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What is a key nursing action for a client with a wound infection?

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.

2. How should a healthcare professional assess a patient with dehydration?

Correct answer: A

Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.

3. A healthcare professional is reviewing the medical history of a client with dementia. Which of the following findings should be addressed immediately?

Correct answer: B

Rationale: Restlessness and agitation in clients with dementia should be addressed immediately as they can indicate underlying causes such as pain, discomfort, or unmet needs. Addressing these symptoms promptly can help prevent the escalation of behavioral issues and improve the client's quality of life. While frequent episodes of wandering at night, mild confusion during the day, and incontinence are also important issues to address in clients with dementia, restlessness and agitation usually require immediate attention to ensure the safety and well-being of the client.

4. What is the appropriate intervention for fluid overload?

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

5. What is an important consideration when administering a blood transfusion?

Correct answer: A

Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.

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