The nurse is bathing a client and discovers a pressure ulcer on the buttocks. Which nursing intervention, following completion of the bath, is completed first?

Correct Answer: A

Rationale: The correct answer is A: Position the client off of the ulcer. This is the first intervention because it helps relieve pressure on the affected area, promoting healing and preventing further damage. By repositioning the client, blood flow is improved, reducing the risk of further tissue breakdown. Choice B (Massage the ulcerated area vigorously) is incorrect as it can cause further damage to the already compromised tissue. Choice C (Place antibiotic cream over the ulcerated area) should only be done after proper assessment and orders from the healthcare provider. Choice D (Notify the health care provider and await orders) is important, but repositioning the client to relieve pressure should be the immediate priority to prevent worsening of the pressure ulcer.

Correct Answer: D

Rationale: The correct answer is D because at Aaron's developmental stage, his peers play a significant role in shaping his identity and providing emotional support. Interacting with his girlfriend and close friends from college allows for social connection, emotional intimacy, and shared experiences, which are crucial for his development. Choices A, B, and C are incorrect as they do not prioritize peer relationships, which are particularly influential during young adulthood in terms of identity formation and social support. Aaron's parents, aunts, uncles, cousins, former high school classmates, and professors may have important roles in his life, but at this stage, peer relationships are paramount.

Correct Answer: B

Rationale: The correct answer is B: Use personal protective equipment (PPE). PPE helps prevent the spread of infectious agents by creating a barrier between the nurse and potentially infectious materials. By wearing PPE, the nurse can protect themselves and others from exposure to harmful pathogens, thus breaking the chain of infection. A: Placing contaminated linens in a paper bag does not directly address the prevention of transmission of infection. C: Covering a cough by placing the mouth in the hand is not an effective infection control measure as it can lead to the spread of germs through contact with surfaces. D: Wearing sterile gloves for client care is important but may not be the most appropriate measure to break the chain of infection in all situations.

Correct Answer: D

Rationale: The correct answer is D. Redness, pain, and edema at the site are classic signs of cellulitis, indicating localized inflammation and infection. BUN and creatinine (choice A) are not specific to cellulitis but may indicate impaired kidney function. Breath sounds (choice B) are related to respiratory assessment and not relevant to cellulitis. Blood cultures (choice C) may be ordered to identify the causative organism but are not immediate assessment findings of cellulitis. In summary, choices A, B, and C do not directly support the diagnosis of cellulitis, while choice D aligns with the typical clinical presentation of the condition.

Correct Answer: D

Rationale: The correct answer is D: Staphylococcus aureus. Staphylococcus aureus is the most common organism responsible for cellulitis due to its ability to invade skin and soft tissues. It produces enzymes and toxins that contribute to tissue damage and inflammation. Staphylococcus epidermidis (A) is a common skin flora but less likely to cause cellulitis. Streptococcus pneumoniae (B) typically causes respiratory infections. Streptococcus viridans (C) is more associated with endocarditis.