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: B

Rationale: The correct answer is B: Urine output monitoring. This method is the best for assessing fluid balance in a client with kidney disease because the kidneys play a key role in regulating fluid balance by controlling urine production. Monitoring urine output provides direct insight into the body's fluid status and kidney function. Daily weight measurements (A) can be influenced by factors other than fluid balance. Electrolyte panel monitoring (C) assesses electrolyte levels, not fluid balance specifically. Monitoring vital signs (D) can give clues to fluid imbalance but is not as direct or specific as urine output monitoring.

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: B

Rationale: The correct answer is A: Eggs. Eggs are considered a complete protein because they contain all 9 essential amino acids required by the human body. This makes them a high-quality protein source. Corn (B), peanuts (C), and sunflower seeds (D) are not complete proteins as they lack one or more of the essential amino acids. Corn is deficient in lysine, peanuts are deficient in methionine, and sunflower seeds are deficient in lysine. Therefore, only eggs provide all the essential amino acids necessary for optimal health and proper bodily functions.

Correct Answer: A

Rationale: The correct answer is A: Turn the client every two hours. This action helps prevent pressure ulcers by relieving pressure on specific areas of the body. Turning the client redistributes pressure, promotes circulation, and reduces the risk of tissue damage. It is a crucial part of pressure ulcer prevention in immobile or bedridden patients. Increasing protein intake (B) may aid in wound healing but does not directly prevent pressure ulcers. Encouraging rest (C) may not address the root cause of pressure ulcers. Applying dressings to wounds (D) is a treatment for existing ulcers, not prevention.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.

Correct Answer: C

Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.

Correct Answer: D

Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.