The nurse has provided education to a client and their family member about how to change wound dressings. Which client statement indicates the need for additional teaching?

"We should look for signs like redness, warmth, and tenderness when changing the dressing."

"Washing my hands before and after the dressing change is important to prevent infection."

"I should change my dressing as prescribed, and if it becomes soiled, wet, or displaced."

"If I see any type of wound drainage, I should immediately go to the nearest hospital."

Answer and Explanation

The Correct Answer is D

A. "We should look for signs like redness, warmth, and tenderness when changing the dressing.": Monitoring for these signs of infection is appropriate and helps ensure timely intervention. Recognizing changes in wound appearance supports safe home care.

B. "Washing my hands before and after the dressing change is important to prevent infection.": Proper hand hygiene is essential for reducing the risk of introducing pathogens to the wound. This statement reflects correct understanding of infection prevention practices.

C. "I should change my dressing as prescribed, and if it becomes soiled, wet, or displaced.": Following the prescribed schedule and replacing compromised dressings helps maintain wound integrity and promotes healing. This demonstrates accurate knowledge of wound care principles.

D. "If I see any type of wound drainage, I should immediately go to the nearest hospital.": Not all drainage requires emergency care. Normal serous or slightly bloody drainage can occur during healing. Immediate hospital visits should be reserved for signs of infection, excessive bleeding, or other complications.

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Correct Answer is B

Explanation

A. The visitor is wearing gloves, gown and a mask while in the room: This indicates proper use of standard and droplet precautions for a client with meningitis. Full personal protective equipment (PPE) helps prevent transmission of infectious agents. This demonstrates adherence to infection control guidelines.

B. The visitor is wearing only gloves while feeding the client in the room: Meningitis, particularly bacterial forms, is transmitted via respiratory droplets. Gloves alone do not protect against inhalation or contact with contaminated secretions. Inadequate PPE increases the risk of infection for the visitor and is a significant concern.

C. The visitor cleaned their hands when entering and leaving the room: Proper hand hygiene reduces the risk of transmitting pathogens to or from the client. Handwashing or using hand sanitizer is a key infection control measure. This practice supports patient and visitor safety.

D. The visitor removed their protective gear before leaving the room: Removing PPE before exiting the room is appropriate to prevent contamination of the external environment. Correct doffing of gear is essential to minimize spread of infectious agents.

A. The new nurse is ventilating the client too slowly. B. The new nurse should prepare to assist with intubation. C. The new nurse is hyperventilating the client. D. The new nurse is appropriately ventilating the client.

Correct Answer is C

Explanation

A. The new nurse is ventilating the client too slowly: Slow ventilation would typically cause a rise in PaCO2 (hypercapnia), not a decrease. A PaCO2 of 30 mm Hg indicates the opposite problem.

B. The new nurse should prepare to assist with intubation: While intubation may be necessary in some situations, a PaCO2 of 30 mm Hg does not indicate imminent respiratory failure. Intubation is not indicated solely based on this capnography reading.

C. The new nurse is hyperventilating the client: A normal PaCO2 range is 35–45 mm Hg. A PaCO2 of 30 mm Hg indicates hypocapnia, most likely from excessive ventilation using the bag-valve mask. Hyperventilation can lead to respiratory alkalosis and reduced cerebral perfusion.

D. The new nurse is appropriately ventilating the client: Appropriate ventilation maintains PaCO2 within normal limits. A value of 30 mm Hg is below normal, indicating over-ventilation rather than correct technique.

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The nurse has provided education to a client and their family member about how to change wound dressings. Which client statement indicates the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a visitor of a client with meningitis. Which finding should concern the nurse?

Correct Answer is B

Explanation

The nurse is watching a new nurse ventilate a client using a bag-valve mask with capnography capabilities. The nurse notices that the client's PaCO2 level is 30 mm Hg. How should the nurse interpret this finding?

Correct Answer is C

Explanation

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