The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:

there is too much moisture present in the wound bed and treatment should be changed.

the wound will require surgical debridement of the nonviable tissue at the wound edges.

the patient requires turning and positioning every two hours.

this is a normal finding that indicates wound healing

Answer and Explanation

The Correct Answer is B

Choice A rationale: White skin around the wound edges is not necessarily indicative of too much moisture in the wound bed.

Choice B rationale: White skin around the wound edges may suggest nonviable tissue, and surgical debridement may be needed.

Choice C rationale: Turning and positioning every two hours is important for preventing pressure injuries but is not directly related to the observed skin color.

Choice D rationale: White skin around the wound edges is not a normal finding and indicates a potential issue with tissue viability.

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Correct Answer is B

Explanation

Choice A rationale: Injecting one mL of air into a vial before withdrawing 20 mg furosemide is an appropriate technique to equalize pressure in the vial.

Choice B rationale: Instructing a client to place a buccal medication under the client's tongue this is a method for administering sublingual medications. Buccal medications are placed between the cheek and the gum and allowed to dissolve slowly.

Choice C rationale: Pouring liquid medication to the 10 ml mark on a medication cup is acceptable, as long as the cup is held at eye level and the lowest point of the meniscus is used to measure the volume.

Choice D rationale: Selecting a 1 ml syringe with a 5/8 inch needle is suitable for giving heparin subcutaneously, as this ensures accuracy and minimizes tissue trauma.

A. stimulate deeper inhalations. B. improve ciliary movement in the bronchioles. C. loosen secretions in congested areas. D. propel oxygen along the respiratory tract.

Correct Answer is C

Explanation

Choice A rationale: Stimulating deeper inhalations is a secondary benefit of CPT, but the primary purpose is to loosen secretions in congested areas.

Choice B rationale: Improving ciliary movement in the bronchioles is a secondary benefit of CPT, but the primary purpose is to loosen secretions.

Choice C rationale: Loosening secretions in congested areas is the primary purpose of CPT for clients with pneumonia.

Choice D rationale: Propelling oxygen along the respiratory tract is not the primary purpose of CPT but may be a secondary benefit.

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The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:

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A nursing instructor is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student requires intervention by the Instructor?

Correct Answer is B

Explanation

Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:

Correct Answer is C

Explanation

A client is admitted to the hospital with a diagnosis of R/O appendicitis. Which abbreviation would describe the location of a client's appendix?

A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states, "I can't catch my breath." Which abbreviation would be used to document this presentation?

The nurse recognizes that which is not a necessary feature of a team?

The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum:

The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:

A client is diagnosed with chronic constipation. The nurse is given an order by the physician to administer a glycerin suppository. What abbreviation will be written in the physician's order for the administration route for the suppository?

It is most critical for the nurse to use a filtered needle when preparing a parenteral medication that:

In order to minimize discomfort when giving an injection to a client, the nurse should: