The client diagnosed with a stage 4 pressure ulcer is being treated with enzymatic debriding agent and occlusive dressing. The nurse notices a foul odor. Which intervention should the nurse implement?

Correct Answer: B

Rationale: The correct answer is B because the foul odor is expected when using enzymatic debriding agents, indicating the breakdown of necrotic tissue. The nurse should explain this to the client to alleviate concerns. Choice A is not necessary as the nurse can handle the situation independently. Choice C is irrelevant to addressing the foul odor. Choice D is not indicated as antibiotics are not typically used for managing a foul odor related to enzymatic debridement.

Correct Answer: C

Rationale: The correct answer is C. Cystic hygromas are lymphatic malformations that are typically located in the neck and are filled with lymphatic fluid. They are supremely transilluminable due to their fluid content, which allows light to pass through easily. This characteristic helps differentiate them from other neck masses. Explanation for other choices: A: They do not arise from the carotid body lymph sac in the neck. Cystic hygromas are not associated with the carotid body. B: They can be unilocular or multilocular, so stating they consist of a unilocular cystic mass is not entirely accurate. D: It is not inherently dangerous to treat cystic hygromas with alcohol sclerotherapy, but careful consideration and expertise are necessary to avoid complications.

Correct Answer: D

Rationale: The correct answer is D: Ultraviolet light. Melanoma is primarily caused by exposure to UV light, which damages skin cells and increases the risk of developing melanoma. UV light triggers mutations in skin cells, leading to the development of melanoma. Age (A), Gender (B), and Ethnicity (C) are not direct risk factors for melanoma, although older individuals and those with fair skin are at higher risk due to increased cumulative UV exposure. UV light is the most significant risk factor for melanoma, making it the correct choice.

Correct Answer: A

Rationale: The correct answer is A: A few minutes before the next scheduled dose of medication. This timing ensures that the trough level represents the lowest concentration of the antibiotic in the client's bloodstream, allowing for an accurate assessment of how well the medication is being metabolized and eliminated. Explanation: 1. Trough level is usually measured just before the next dose to ensure that the drug has reached its lowest concentration. 2. This timing helps determine if the drug concentration remains within the therapeutic range and if adjustments to the dosing regimen are needed. 3. Option B is incorrect because waiting 1-2 hours after oral administration would not reflect the trough level. 4. Option C is incorrect as measuring 30 minutes after IV administration would not capture the trough level accurately. 5. Option D is incorrect because measuring during infusion would not provide an accurate trough level. In summary, the trough level should be ordered just before the next dose to accurately assess the drug's concentration at its lowest point.

Correct Answer: A

Rationale: The correct answer is A: Question the client about the cause of the bruises. This is the first action indicated because it allows the nurse to gather more information directly from the client to understand the potential cause of the bruises. By communicating with the client, the nurse can assess if the bruises are due to accidental bumps, medication side effects, abuse, or other underlying health issues. This direct communication is crucial for determining the appropriate follow-up actions. Summary of other choices: B: Discussing with the client's spouse does not directly involve the client, who should be the primary source of information. C: Documenting the bruises is important but does not address the immediate need to gather more information from the client. D: Contacting the supervisor is premature without first gathering information from the client.