What is the best nursing action for a client with a wound infection?

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing. Explanation of why other choices are incorrect: B: Applying a sterile dressing is important for wound care but does not address the underlying infection. C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection. D: Placing the client in a sitting position is not relevant to treating a wound infection.

Correct Answer: C

Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.

Correct Answer: A

Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.

Correct Answer: A

Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.

Correct Answer: C

Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.

Correct Answer: A

Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care. Summary of other choices: B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language. C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication. D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.

Correct Answer: C

Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.

Correct Answer: C

Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively. A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality. B: "Has no health problems" is important information but does not require immediate further exploration. D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.