The nurse is planning discharge teaching to a client with diabetes who has a large wound. Which is the priority action for the nurse prior to initiating teaching with this client?

Correct Answer: A

Rationale: The priority action for the nurse before initiating discharge teaching with a client with diabetes and a large wound is to assess the client's current knowledge regarding dressing changes. This step is crucial as it helps the nurse to understand the client's baseline understanding and skills related to wound care, which will guide the teaching process effectively. By asking the client to state what they know about the current dressing changes, the nurse can identify any knowledge gaps or misconceptions that need to be addressed. This assessment will ensure that the teaching is tailored to the client's specific needs and promotes successful wound healing and overall diabetes management.

Correct Answer: B

Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.

Correct Answer: C

Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.

Correct Answer: B

Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.

Correct Answer: D

Rationale: Terazosin is an alpha-1 adrenergic receptor blocker. By blocking alpha-1 receptors in the vascular smooth muscle, terazosin causes dilation of both arteries and veins, leading to reduced peripheral vascular resistance and decreased blood pressure. This dilation effect is achieved by preventing the binding of norepinephrine to alpha-1 receptors, thereby inhibiting vasoconstriction. Terazosin is commonly used in the treatment of hypertension to help lower blood pressure by reducing the workload on the heart and improving blood flow to organs and tissues.