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Questions 164

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Question 1 of 5

The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?

Correct Answer: D

Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.

Question 2 of 5

The nurse in a residence facility for older adults is planning for the year. During which month should the influenza vaccine be offered to the residents?

Correct Answer: C

Rationale: September allows influenza vaccination before the flu season peaks, ensuring immunity. Later or earlier months are less optimal.

Question 3 of 5

The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?

Correct Answer: D

Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.

Question 4 of 5

The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?

Correct Answer: D

Rationale: Foods rich in vitamin K. Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin's effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.

Question 5 of 5

A client is admitted for COPD. Which findings would require the nurse's immediate attention?

Correct Answer: B

Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.

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