A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Implementation.

Planning.

Evaluation.

Assessment.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.

Choice B rationale:

Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.

Choice C rationale:

Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.

Choice D rationale:

Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.

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Correct Answer is A

Explanation

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

A. Autonomy. B. Beneficence. C. Veracity. D. Fidelity.

Correct Answer is B

Explanation

Choice A rationale:

Autonomy refers to a patient's right to make their own decisions about their medical care. While autonomy is an important ethical principle, it is not directly related to the situation described. The nurse providing oxygen therapy to the patient without the patient's consent is not an example of respecting autonomy.

Choice B rationale:

Beneficence is the correct choice. Beneficence is the ethical principle of doing what is best for the patient's well-being. In this situation, providing oxygen therapy to a patient experiencing difficulty in breathing aligns with the principle of beneficence. Oxygen therapy aims to improve the patient's oxygenation and alleviate respiratory distress.

Choice C rationale:

Veracity refers to truthfulness and honesty in communication. While honesty is important, it is not the primary ethical principle at play in this situation. Providing oxygen therapy to improve the patient's condition is more aligned with beneficence.

Choice D rationale:

Fidelity refers to the duty to be faithful and keep promises. While fidelity is important in maintaining trust between healthcare providers and patients, it is not the primary principle relevant here. The priority is to address the patient's immediate health needs through appropriate interventions like oxygen therapy.

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A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Correct Answer is A

Explanation

A patient has difficulty in breathing. The nurse provides oxygen therapy to the patient, after which the patient feels better. Which principle is involved in this situation?

Correct Answer is B

Explanation

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