Correct Answer: C

Rationale: Rotating the swab over necrotic tissue is not recommended because necrotic tissue does not provide an accurate representation of the microorganisms present in the wound. Necrotic tissue is dead tissue, and culturing it can lead to misleading results, as it may not reflect the current state of infection or the microorganisms causing the infection. Obtaining the sample from the outer edge of the wound is also not ideal. The outer edge of the wound may be contaminated with skin flora or other external contaminants, which can lead to inaccurate culture results. The sample should be taken from clean, viable tissue within the wound bed to ensure accurate identification of the microorganisms present. Applying sterile gloves to remove the outer dressing is the correct action. This step is crucial to maintain aseptic technique and prevent contamination of the wound and the specimen. Sterile gloves help ensure that the nurse does not introduce any external microorganisms into the wound while handling the dressing. Crushing the transport medium after obtaining the specimen is a necessary step to activate the medium and preserve the specimen during transport to the laboratory. However, this step comes after the specimen has been collected and does not directly relate to the technique of obtaining the specimen.

Correct Answer: B,C,D

Rationale: When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors. At the client's bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the 'three checks' process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors. Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the 'three checks' and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen. While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the 'three checks' and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection. When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.

Correct Answer: A

Rationale: Quick-release ties ensure safety by allowing rapid removal in emergencies. A prescription is needed but not the first action. Securing to side rails risks injury, and two fingers (not three) is the correct spacing.

Correct Answer: A

Rationale: Walking is a weight-bearing exercise, which is crucial for maintaining bone density and reducing the risk of osteoporosis. Regular physical activity, especially weight-bearing exercises like walking, helps stimulate bone formation and slows down bone loss. The National Osteoporosis Foundation recommends at least 30 minutes of weight-bearing exercise on most days of the week to help prevent osteoporosis. Avoiding sun exposure is not advisable for reducing the risk of osteoporosis. Sunlight is a natural source of vitamin D, which is essential for calcium absorption and bone health. While excessive sun exposure can be harmful, moderate exposure helps the body produce sufficient vitamin D.
Therefore, avoiding sun exposure entirely can lead to vitamin D deficiency, increasing the risk of osteoporosis. The recommended daily intake of calcium for older adults is significantly higher than 250 milligrams. For adults aged 51 and older, the National Institutes of Health recommends 1,200 milligrams of calcium per day. Adequate calcium intake is vital for maintaining bone health and preventing osteoporosis.
Therefore, taking only 250 milligrams of calcium per day is insufficient to meet the body's needs. Dairy products are a primary source of calcium, which is essential for bone health. Reducing the intake of dairy products can lead to inadequate calcium intake, increasing the risk of osteoporosis. Instead, older adults should ensure they consume enough dairy or other calcium-rich foods to meet their daily calcium requirements.

Correct Answer: A

Rationale: Airborne precautions are necessary for clients with tuberculosis (T
B) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others. Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections. Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB. Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.