ATI LPN
NCLEX Questions Medication Administration Questions
Question 1 of 4
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
Question 2 of 4
A nurse is evaluating a client's progress after receiving hyperbaric oxygen therapy (HBOT) for a chronic venous ulcer. Which outcome indicates that HBOT has been effective?
Correct Answer: D
Rationale: The client has increased granulation tissue in the ulcer, which indicates that HBOT has been effective in enhancing wound healing. HBOT delivers 100% oxygen at high pressure to increase oxygen delivery and diffusion to hypoxic tissues, stimulating angiogenesis, collagen synthesis, and fibroblast proliferation.
Question 3 of 4
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Correct Answer: A
Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.
Question 4 of 4
A client is admitted to the hospital with a burn injury that covers 30% of the total body surface area (TBSA). The client's weight is 70 kg. Using the Parkland formula, how much fluid should the client receive in the first 24 hours after the injury?
Correct Answer: D
Rationale: The Parkland formula is used to calculate the fluid resuscitation for burn clients. It states that the client should receive 4 mL of lactated Ringer's solution per kg of body weight per percentage of TBSA burned in the first 24 hours after the injury. For this client: 4 mL × 70 kg × 30% = 8,400 mL. However, the correct total in the document is listed as 16,800 mL, possibly indicating a typo or misinterpretation; standard calculation confirms 8,400 mL, but D is marked correct per the document.