A nurse is preparing to perform a wound irrigation procedure for a patient with a contaminated wound. What solution should the nurse use for wound irrigation?

Correct Answer: B

Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.

Correct Answer: C

Rationale: The symptoms of polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger) are classic signs of diabetes mellitus. In this case, the presence of hyperglycemia (high blood sugar) and glycosuria (glucose in the urine) further support the diagnosis of diabetes mellitus. Insulin deficiency or resistance in diabetes leads to impaired glucose utilization and excessive glucose in the bloodstream, causing the classic symptoms observed in the patient. Hyperthyroidism, hypothyroidism, and Cushing's syndrome do not typically present with the hallmark symptoms of polyuria, polydipsia, and polyphagia associated with uncontrolled diabetes mellitus.

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.

Correct Answer: A

Rationale: The presentation described indicates a candidal infection, which commonly occurs in warm, moist body areas like inguinal folds and gluteal cleft. The pruritic, erythematous rash with scaly plaques and satellite papules and pustules is characteristic of cutaneous candidiasis. The recent antibiotic use for urinary tract infection likely disrupted the normal skin flora, predisposing the patient to a Candida overgrowth. Tinea cruris (jock itch) can also present similarly, but the presence of satellite papules and pustules is more indicative of candidiasis. Erythrasma typically presents as well-defined brown-red patches without satellite lesions, and intertrigo is a more generic term referring to inflammation of skin folds that can have various causes, including candidiasis.

Correct Answer: A

Rationale: Urinary tract infections are strongly associated with the occurrence of preterm labor. It is important to screen for and address any urinary tract infections during pregnancy to reduce the risk of complications like preterm labor. Diagnostic procedures, such as obtaining a urine sample for testing, help healthcare providers identify and treat any infections promptly to promote a healthy pregnancy. Therefore, the nurse can explain to Patient Presley that the diagnostic procedure is necessary to detect and address any potential urinary tract infections that could impact her pregnancy.

Correct Answer: A

Rationale: Nicotine, a substance found in cigarettes, is known to have harmful effects on pregnancy. Smoking during pregnancy can lead to numerous complications, one of which is the increased risk of delivering a low birth weight infant. Low birth weight infants are born weighing less than 5.5 pounds (2.5 kilograms) and are at a higher risk of various health issues, developmental delays, and even mortality. Therefore, Nurse Emma advised the patient to quit smoking to reduce the risk of having a low birth weight infant.

Correct Answer: D

Rationale: Prinzmetal's angina, also known as variant angina, is characterized by episodes of chest pain that occur at rest and are relieved by nitroglycerin. Patients with Prinzmetal's angina may also have transient ST-segment elevation on an electrocardiogram (ECG) during episodes of chest pain. This is due to coronary artery vasospasm, which causes temporary obstruction of blood flow to the heart muscle. Stable angina typically presents with chest pain on exertion that resolves with rest, while unstable angina and acute myocardial infarction present with chest pain that is not relieved with nitroglycerin and are associated with more severe coronary artery disease.

Correct Answer: C

Rationale: The APCAR (Appearance, Pulse, Grimace, Activity, Respiration) score is used to evaluate a newborn's condition in the first few minutes after birth. This assessment typically occurs within the first 1 to 3 minutes after the baby is born. The score helps healthcare providers quickly assess the baby's overall well-being and determine if any immediate interventions or further monitoring are necessary.

Correct Answer: A

Rationale: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.