A nurse is assisting with developing a plan of care for a client.

Exhibit 1

Nurses' Notes

2 days ago:

Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.

Today, 0900:

Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.

Complete the following sentence by using the lists of options.

The nurse understands that which of the following dressing should be added to the plan of care Select...

hydrocolloid

dry gauze

hydrogel

alginate

transparent

Answer and Explanation

Correct Answer : A

A. A hydrocolloid dressing is a type of dressing that is used for wounds with minimal exudate, such as the wound on the client's coccyx described in the scenario. It provides a moist environment for wound healing and can help with pain relief. This type of dressing is suitable for wounds with granulation tissue and can help protect the wound from further damage while promoting healing.

B. A dry gauze is not appropriate for this type of wound as it does not provide the necessary moist environment for healing and may adhere to the wound, causing damage upon removal.

C. A hydrogel dressing is typically used for wounds with moderate to heavy exudate.

D. An alginate dressing is typically used for wounds with moderate to heavy exudate. These dressings may not be suitable for the described wound with minimal exudate.

E. A transparent dressing may not be suitable for a wound with granulation tissue and moderate exudate, as it may not provide adequate protection and moisture to the wound.

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Correct Answer is D

Explanation

Rationale:

A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.

B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.

C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.

D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.

A. Physical therapy for muscle-strengthening and balance-training B. Calcium 1500 mg po once daily on empty stomach C. Vitamin D supplement 2.500 units daily D. Home health evaluation of home safety E. Increase caffeine intake F. Increase daily sun exposure

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A. Physical therapy for muscle-strengthening and balance-training is expected because the client has a left lateral malleolus fracture and a Bone Mineral Density DEXA scan of -3.8. Physical therapy can help with rehabilitation and prevent future falls.
B. Calcium supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Calcium supplementation is essential for bone health.
C. Vitamin D supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Vitamin D supplementation is essential for calcium absorption and bone health.
D. A home health evaluation of home safety is expected because the client lives alone and has a history of falling. A home health evaluation can help identify potential hazards and improve safety.
E. Increasing caffeine intake is unexpected because the client already reports consuming at least 3 cups of coffee daily. Increasing caffeine intake further may not be advisable due to potential side effects, such as increased heart rate and blood pressure.
F. Increasing daily sun exposure is unexpected because the client has osteoporosis and a history of falling. Excessive sun exposure can increase the risk of skin cancer, and the client may not be able to safely spend extended periods of time in the sun due to mobility limitations. Additionally, vitamin D supplementation is usually recommended over sun exposure for individuals with osteoporosis.

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A nurse is assisting with developing a plan of care for a client. Exhibit 1

Nurses' Notes

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

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A nurse is assisting with developing a plan of care for a client.

Exhibit 1