The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Prevent introduction of different organisms into the wound

Decrease swelling in wound area from accumulation of organisms

Decrease the pain caused by organisms that may have collected

Render area sterile

Answer and Explanation

The Correct Answer is A

A.   Cleaning the wound from the inner to outer area helps prevent introducing microorganisms from the surrounding skin into the wound, reducing the risk of infection.
B.   While preventing infection may indirectly reduce swelling associated with inflammation, the primary rationale for cleansing the wound in this manner is to minimize the introduction of microorganisms.

C.   Pain reduction is not the primary goal of cleaning the wound from the inner to outer area, although minimizing the risk of infection may help prevent secondary pain caused by infection.
D.   While maintaining a clean environment is essential for wound care, the goal of cleansing the wound in this manner is to reduce the risk of introducing microorganisms, not to achieve sterility.

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Correct Answer is D

Explanation

A. While generalized malaise can occur with inflammatory conditions, it is not a hallmark symptom of ankylosing spondylitis.
B. Ankylosing spondylitis primarily affects the spine and sacroiliac joints, not typically the ankles.
C. Deformities of fingers and toes are not characteristic of ankylosing spondylitis; they are more commonly associated with conditions like rheumatoid arthritis.
D. Ankylosing spondylitis is characterized by progressive stiffness and fusion of the spine, leading to decreased mobility and flexibility, especially in the lower back.

A. Whole wheat pasta B. Broccoli C. Shellfish D. Cranberries

Correct Answer is C

Explanation

A. Whole wheat pasta is not typically high in purines.

B. Broccoli is a vegetable and generally not high in purines.

C. Shellfish, such as shrimp, crab, and lobster, are high in purines and should be avoided by individuals with gout.
D. Cranberries are fruits and are generally low in purines.

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The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who was recently diagnosed with Ankylosing Spondylitis. Which of the following symptoms would the nurse expect in this client?

Correct Answer is D

Explanation

A client diagnosed with gout has been instructed on limiting the intake of purine-rich foods. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer is C

Explanation

A nurse is providing health teaching to a client about ways a communicable disease is transmitted by contact. Select all that apply.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

A nurse is caring for a client who has a wound infection. Wound cultures identify the infecting organism as vancomycin-resistant enterococci (VRE). Which type of precautions should the health care team initiate?

The nurse is caring for several clients on a hospital's surgical unit. Which of the following clients are at greatest risk for developing an infection?

The nurse is caring for a client who was diagnosed with "gouty arthritis." Which laboratory test is most important to perform to confirm this diagnosis?

Tumor staging includes the TNM classification system. The N in TNM would give the physician information on which part of the tumor classification?

A nurse is attending a continuing education course about communicable diseases. During which phase does the client develop non-specific symptoms such as malaise, fever, and body aches?

The culture from the wound infection shows the organism: Bacterial Staphylococcal Aureus. Which of the following healthcare provider orders would the nurse anticipate?