What is the most important intervention for a client with a wound infection?

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.

Correct Answer: D

Rationale: The correct answer is D: culturalism. The nurse's conclusion that the patient's inability to maintain her diet and diabetic regime is due to the foods she eats reflects culturalism. Culturalism refers to the belief that a person's behaviors and beliefs are solely determined by their culture. In this case, the nurse is attributing the patient's struggles solely to her cultural background without considering other factors. A: Cultural sensitivity is about being aware and respectful of different cultures, but it does not involve making assumptions based on culture alone. B: Cultural safety is about creating a safe and respectful environment for individuals from different cultures, but it does not involve making assumptions about behavior solely based on culture. C: Cultural perspective involves understanding different cultural viewpoints, but it does not involve making assumptions about behavior solely based on culture. In summary, the nurse's conclusion is an example of culturalism as it oversimplifies the patient's situation by attributing her struggles solely to her cultural background.

Correct Answer: A

Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage. Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function. Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI. Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI. Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI. Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.

Correct Answer: C

Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.

Correct Answer: B

Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.

Correct Answer: B

Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life. Summary of Incorrect Choices: A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity. B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation. D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.

Correct Answer: A

Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.

Correct Answer: A

Rationale: The correct answer is A: Encouraging early ambulation to prevent deep vein thrombosis. Early ambulation helps prevent blood clot formation in the legs, reducing the risk of deep vein thrombosis post-surgery. It also promotes circulation and aids in preventing complications like pneumonia. Administering pain medication (B) is important, but preventing complications should take priority. Providing wound care (C) is essential but not the top priority. Encouraging a high-protein diet (D) is beneficial for healing, but immediate post-operative mobility is crucial for preventing complications.