The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

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Question 1 of 5

The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Correct Answer: D

Rationale: Hydrocolloid promotes healing in stage 2 by creating a moist wound bed. Alginate dressings are for stage 3 and 4 injuries to absorb drainage, moist gauze is for stage 4 or unstageable dressing that need debridement, transparent dressings are for stage 1 to prevent further friction.

Question 2 of 5

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: Administer the medication with the needle at a 45 degree angle. Subcutaneous injections should be inserted at 45 to 90 degree angles. Enoxaparin is given in the abdomen, and the Z-track method is for IM injections. Massaging the site of an anticoagulant will increase bruising.

Question 3 of 5

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?

Correct Answer: B

Rationale: We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

Question 4 of 5

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many ml/hr? (Round to nearest whole number)

Correct Answer: B

Rationale: 107 ml/hr. Calculation: 750 ml ÷ 7 hr = 107.14 ml/hr, rounded to 107.

Question 5 of 5

A nurse is preparing a change of shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Correct Answer: B

Rationale: Situation, background, assessment, and recommendation.

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