The number of dressing forceps pairs in a complete wound dressing pack is:

Correct Answer: B

Rationale: The correct answer is B: 2. In a complete wound dressing pack, there are typically 2 pairs of dressing forceps included. This is because having 2 pairs allows for efficient handling and manipulation of dressings and wound care materials during the procedure. Choice A (1) is incorrect as having only 1 pair would limit the ability to work smoothly. Choices C (3) and D (4) are incorrect as having an excess number of forceps pairs would be unnecessary and could lead to confusion and inefficiency during the dressing change process.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Nurse Trish's first response should be to cover the wound with a saline-soaked sterile dressing to prevent infection and keep the exposed tissues moist. 2. This action helps protect the wound and organs from further damage or contamination. 3. It is important to maintain the sterility of the dressing to minimize the risk of infection. 4. Calling the physician can be the next step after stabilizing the wound with the dressing. 5. Taking blood pressure and pulse is important but not the immediate priority in this situation. 6. Pulling the dehiscence closed is contraindicated as it can cause further harm and should not be attempted by the nurse.

Correct Answer: C

Rationale: The correct answer is C: Chronic obstructive bronchitis. A 56-year-old client with chronic cough, peripheral edema, and cyanotic nail beds likely has chronic obstructive bronchitis due to the presence of chronic cough and cyanosis, which are common symptoms. Peripheral edema can be seen in advanced stages. ARDS (choice A) is typically seen in acute conditions, not chronic. Asthma (choice B) usually presents with wheezing and shortness of breath, not peripheral edema. Emphysema (choice D) is characterized by shortness of breath and barrel chest, not peripheral edema or cyanosis.

Correct Answer: A

Rationale: The correct answer is A: Keep a closed sterile drainage system. This is crucial to prevent infection by maintaining a closed system, reducing the risk of introducing bacteria into the bladder. The closed system prevents ascending infection. Choice B is incorrect because routine catheter irrigation can introduce pathogens into the bladder. Choice C is incorrect because keeping the bag lower than the bed can lead to reflux of urine back into the bladder, increasing the risk of infection. Choice D is incorrect because while measuring intake and output is important for monitoring fluid balance, it is not a direct safety measure for catheter care.

Correct Answer: D

Rationale: The correct answer is D because it follows the PES format, which stands for Problem (nursing diagnosis), Etiology (related factor), and Signs/Symptoms (defining characteristics). In this case, the Problem is "Self-esteem disturbance," the Etiology is "related to rejection by the husband," and the Signs/Symptoms are "manifested by crying and isolation." The other options do not follow the PES format correctly. A lacks defining characteristics, B does not have a clear related factor, and C does not have a problem clearly identified. Thus, D is the correct choice as it adheres to the PES structure for nursing diagnosis formulation.