Which of the following interventions is most appropriate for a client with a deep wound infection?

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Question 1 of 9

Which of the following interventions is most appropriate for a client with a deep wound infection?

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Question 2 of 9

Which of the following is the most important intervention for a client with hypovolemic shock?

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In hypovolemic shock, the primary issue is a lack of circulating blood volume. Administering fluids helps to restore blood volume and improve perfusion to vital organs, addressing the underlying cause of shock. Vasopressors (B) are used in distributive shock, sodium bicarbonate (C) is used for metabolic acidosis, and corticosteroids (D) are typically not indicated in hypovolemic shock. Administering fluids is the most important intervention to stabilize the client's condition in hypovolemic shock.

Question 3 of 9

Which of the following foods should a client with hypercholesterolemia decrease in their diet?

Correct Answer: B

Rationale: The correct answer is B: Hamburgers. Clients with hypercholesterolemia should decrease their intake of saturated fats and cholesterol. Hamburgers are typically high in saturated fats and cholesterol due to the ground beef patty and cheese. Broiled catfish (A) is a lean protein source and can be a healthier option. Wheat bread (C) is a good source of fiber and can help lower cholesterol levels. Fresh apples (D) are a healthy choice low in saturated fats and cholesterol. Therefore, hamburgers should be decreased in the diet to manage hypercholesterolemia effectively.

Question 4 of 9

Which action should the nurse take when a client exhibits signs of infection at a surgical site?

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

Question 5 of 9

What is the nurse's priority when caring for a client with a fractured femur?

Correct Answer: A

Rationale: The correct answer is A: Apply a traction splint. The priority for a client with a fractured femur is to immobilize the fracture to prevent further injury and reduce pain. Applying a traction splint helps stabilize the fracture and reduce risk of complications such as nerve or blood vessel damage. Administering pain medication (B) is important but not the priority. Placing the client in a supine position (C) may be needed for comfort but does not address the primary concern of stabilizing the fracture. Administering IV antibiotics (D) is not necessary for a fractured femur unless there are signs of infection.

Question 6 of 9

What is mammography used to detect?

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue by taking X-ray images. Tumors can be cancerous or benign, making early detection crucial for treatment. Pain (A) is a symptom, not detected by mammography. Edema (C) is swelling caused by fluid retention, not a primary target of mammography. Epilepsy (D) is a neurological disorder, unrelated to mammography's purpose. Therefore, the correct answer is B.

Question 7 of 9

A nurse is teaching a patient about managing hypertension. Which of the following dietary changes should the nurse recommend?

Correct Answer: B

Rationale: Step 1: Increasing potassium intake helps lower blood pressure by counteracting the effects of sodium. Step 2: Potassium helps relax blood vessel walls, reducing blood pressure. Step 3: Adequate potassium intake also helps the body balance fluids and maintain normal blood pressure. Summary: A - Increasing sodium intake is counterproductive for hypertension. C - Limiting caffeine helps, but not as directly as increasing potassium. D - Fruits and vegetables are important for a heart-healthy diet and should not be reduced.

Question 8 of 9

What is the appropriate response when a client asks about the safety of drinking alcohol during pregnancy?

Correct Answer: A

Rationale: The correct answer is A because the amount of alcohol that is safe during pregnancy is unknown. It is recommended to avoid alcohol completely to prevent any potential harm to the developing fetus. B is incorrect because there is no known safe level of alcohol consumption during pregnancy. C is incorrect as any amount of alcohol can potentially harm the fetus. D is incorrect as using alcohol to relax during pregnancy is not recommended due to the associated risks.

Question 9 of 9

Which of the following individuals would the nurse consider at highest risk for a suicide attempt?

Correct Answer: D

Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.

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