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A nurse on the medical-surgical unit is planning care for a male client after reviewing their electronic health record (EHR).

Exhibits

Which of the following provider prescriptions should the nurse anticipate receiving to implement in the client's plan of care?

Select 3 provider prescriptions.

Encourage client to consume foods with zinc.

Apply ice pack to left foot for 30 min/hr.

Administer an oral antiviral medication.

Obtain a culture of the client's wound.

Administer tetanus toxoid injection.

Apply transparent dressing over the client's wound.

Place client in airborne precautions.

Answer and Explanation

Correct Answer : A,D,E

A. Encourage client to consume foods with zinc: Zinc plays an important role in wound healing and immune function. Since this client has diabetes and an infected wound, zinc-rich foods can support tissue repair and recovery, making this prescription appropriate.

B. Apply ice pack to left foot for 30 min/hr: Ice is not appropriate for an infected wound because it can impair circulation and slow healing. Instead, treatment should focus on infection management, wound care, and improving blood flow.

C. Administer an oral antiviral medication: The client’s presentation is consistent with a bacterial infection, not a viral process. Purulent drainage, fever, and wound infection require antibacterial therapy, not antiviral medications.

D. Obtain a culture of the client's wound: Wound culture is necessary to identify the causative organism and guide antibiotic therapy. This is an important step in managing diabetic foot infections, which often involve resistant bacteria.

E. Administer tetanus toxoid injection: Since the wound occurred after stepping on glass or metal, there is a risk of tetanus exposure. Administering a tetanus booster is recommended if vaccination is not up to date or uncertain.

F. Apply transparent dressing over the client's wound: Transparent dressings are not suitable for infected wounds with drainage because they can trap moisture and bacteria. Instead, absorbent dressings should be used to promote healing.

G. Place client in airborne precautions: Airborne precautions are for illnesses such as tuberculosis or measles. A foot wound infection does not spread via airborne transmission, so this is unnecessary.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E","F","H","I"]

Explanation

Rationale for Correct Choices:
• Client reports abdominal pain as a 9 on a pain scale of 0 to 10: Severe abdominal pain indicates significant underlying pathology. In the presence of vomiting, distention, and altered bowel sounds, it could reflect obstruction, ischemia, or peritonitis, requiring urgent intervention.

• Abdomen is distended and firm: Distention and firmness suggest accumulation of gas or fluid within the abdomen. This is concerning for bowel obstruction or peritonitis, which can compromise circulation and lead to sepsis if untreated.

• Bowel sounds are distant and hypoactive: Diminished bowel sounds point to decreased peristalsis. In a client with abdominal pain and distention, this strongly suggests obstruction or ileus, requiring prompt diagnostic and therapeutic measures.

• Perianal skin is excoriated, and small ulceration is noted: Frequent diarrhea has led to skin breakdown and ulceration. This not only causes pain and discomfort but also increases the risk of secondary infection, requiring local wound care and protection.

• Tenting of skin for 4 seconds is noted: Delayed skin turgor indicates poor hydration status. Given this client’s vomiting, diarrhea, and low oral intake, this is a strong indicator of fluid volume deficit needing IV replacement.

• Temperature 38.7 °C (101.7 °F): Fever signals the presence of infection. With gastrointestinal complaints, this may be due to bacterial gastroenteritis, abscess formation, or other intra-abdominal infection that warrants further evaluation.

• Mucous membranes are dry: Dry mucous membranes reflect fluid volume depletion. This is consistent with the client’s history of poor intake, vomiting, and diarrhea, and further confirms dehydration.

Rationale for Incorrect Choices:

• Skin is warm and dry: Warm, dry skin suggests adequate peripheral perfusion and does not require follow-up compared to more urgent findings like dehydration and abdominal changes.

• Capillary refill is 2 seconds: A refill time under 3 seconds indicates sufficient peripheral circulation. This finding is within normal limits and does not require additional intervention.

• Respiratory rate 20/min: A respiratory rate within the range of 12–20 breaths/min is considered normal for adults. This shows stable respiratory function and does not require follow-up.

A. Insert an indwelling urinary catheter. B. Use an alcohol-free barrier product. C. Reposition the client every 4 hr. D. Massage the skin over bony prominences.

Correct Answer is B

Explanation

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

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Body System	Findings
Gastrointestinal	Client reports abdominal pain as a 9 on a pain scale of 0 to 10. Abdomen is distended and firm. Bowels sounds are distant and hypoactive.
Integumentary	Skin is warm and dry. Perianal skin is excoriated, and small ulceration is noted.
Fluid balance	Tenting of skin for 4 seconds is noted. Capillary refill is 2 seconds. Temperature 38.7° C (101.7° F) Mucous membranes are dry. Respiratory rate 20/min

A nurse on the medical-surgical unit is planning care for a male client after reviewing their electronic health record (EHR). Exhibits Which of the following provider prescriptions should the nurse anticipate receiving to implement in the client's plan of care? Select 3 provider prescriptions.

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A nurse on the medical-surgical unit is planning care for a male client after reviewing their electronic health record (EHR).

Exhibits

Which of the following provider prescriptions should the nurse anticipate receiving to implement in the client's plan of care?

Select 3 provider prescriptions.