The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?

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Fundamentals Wound Care and Skin Integrity Questions Questions

Question 1 of 5

The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?

Correct Answer: A

Rationale: A hemoglobin of 8.1 g/dL indicates significant postoperative blood loss, requiring immediate intervention.

Question 2 of 5

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?

Correct Answer: C

Rationale: Rewrapping with an elastic compression bandage maintains pressure to reduce edema and shape the residual limb for prosthetic fitting, addressing the immediate need after the bandage comes off.

Question 3 of 5

The employee health nurse is teaching a class on 'Preventing Eye Injury.' Which information should be discussed in the class?

Correct Answer: A

Rationale: Reading instructions ensures proper use of tools and chemicals, a fundamental step in preventing eye injuries across various scenarios.

Question 4 of 5

Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?

Correct Answer: B

Rationale: Placing a tuning fork on the big toe tests vibration sense (via cranial nerve VIII and peripheral nerves), a standard neurological assessment technique.

Question 5 of 5

The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.

Correct Answer: A

Rationale: Yellow spots may indicate retinopathy, requiring immediate medical evaluation.

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