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: A

Rationale: The presentation described is consistent with anterior uveitis. Anterior uveitis involves inflammation of the iris and ciliary body. Patients typically present with symptoms such as redness, pain, photophobia, and blurred vision. The slit-lamp examination findings of ciliary injection (redness and dilation of blood vessels in the iris and ciliary body), corneal edema, and a mid-dilated pupil with a fixed reaction to light (due to ciliary muscle spasm causing decreased accommodation) are characteristic of anterior uveitis. This condition is often idiopathic but can be associated with various systemic diseases like ankylosing spondylitis, inflammatory bowel disease, and other autoimmune disorders. Treatment involves addressing the inflammation with topical corticosteroids and, in some cases, cycloplegic agents to reduce pain and inflammation.

Correct Answer: B

Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.

Correct Answer: A

Rationale: The bioethical issue described in option A revolves around the concept of advance directives. Advance directives are legal documents that outline a person's wishes regarding medical treatment in the event that they are unable to communicate those wishes themselves. In this scenario, the issue pertains to the withholding of food and treatment based on a written advance directive that was made before the patient suffered permanent brain damage. This raises important ethical considerations about respecting a patient's autonomy and adhering to their previously expressed wishes, even in difficult circumstances. The decision to withhold treatment in such a situation is a complex bioethical issue that needs to be handled carefully while balancing the principles of autonomy and beneficence.

Correct Answer: B

Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.

Correct Answer: B

Rationale: Human chorionic gonadotropin (HCG) can be detected in the blood as early as 10 days after the last menstrual period. This hormone is produced by the placenta shortly after the embryo attaches to the uterine lining. Pregnancy tests detect HCG levels to determine pregnancy status, and the hormone can be detected earlier in the blood compared to urine tests. Detecting HCG in the blood at around 10 days post ovulation is often the earliest point when a blood test can confirm pregnancy.

Correct Answer: A

Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.

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: C

Rationale: In response to chronic hypoxia, the body adapts to increase oxygen delivery to tissues by increasing cardiac output. This is achieved by increasing the heart rate and stroke volume, allowing more oxygenated blood to be pumped to the tissues. The increased cardiac output helps compensate for the lower oxygen levels in the blood, ensuring that tissues receive an adequate supply of oxygen despite the hypoxic conditions. This physiological adaptation is essential for maintaining tissue oxygenation and supporting overall cellular function in the presence of chronic hypoxia.