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 C

Explanation

Choice A rationale: Pulling the auricle up and back is the correct procedure for adults when administering ear drops.

Choice B rationale: Having the client pull down on the earlobe is not the correct procedure for administering ear drops in adults.

Choice C rationale: Pulling the auricle up and back is the appropriate technique for adults to straighten the ear canal for proper administration.

Choice D rationale: Warming ear drops in the microwave is not recommended; medications should be administered at room temperature.

A. compensate for an ongoing problem affecting other fluid or electrolytes. B. Increase urine specific gravity to 1.045. C. move fluid into an area that is physiologically unavailable. D. correct imbalance in fluid and electrolytes. E. expand intravascular volume.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Compensating for an ongoing problem affecting other fluid or electrolytes is a common rationale for IV therapy.

Choice B rationale: Increasing urine specific gravity to 1.045 is not a typical goal for IV therapy. IV therapy would decrease the urine specific gravity by diluting the urine with fluids.

Choice C rationale: Moving fluid into an area that is physiologically unavailable is not a primary goal of IV therapy. Physiologically unavailable areas are those that are separated from the rest of the body by a membrane or barrier, such as the cerebrospinal fluid, the intraocular fluid, or the pleural fluid. IV therapy does not cross these barriers and only affects the intravascular and interstitial spaces.

Choice D rationale: Correcting imbalance in fluid and electrolytes is a primary goal of IV therapy.

Choice E rationale: Expanding intravascular volume is a common goal of IV therapy, especially in cases of dehydration or hypovolemia.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is to receive ear drops four times a day to treat an inner ear infection. What is the correct nursing procedure to follow when administering this type of medication?

Correct Answer is C

Explanation

The nurse understands that the rationale(s) for clients receiving intravenous (IV) therapy is/are to: (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

The nurse recognizes ten "rights" associated with giving medications to clients. Which are included in this group? (SELECT ALL THAT APPLY)

The nurse finds a client on bed rest experiencing clear signs of dyspnea. The nurse should assist the client to a:

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

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The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

The client has had a surgical debridement of a wound, which is starting to heal. In order to further promote healing, this client should be encouraged to consume a balanced diet with emphasis on increased:

The nurse is giving vancomycin to a client and must hold the dose until the results of the trough level are known. This term is associated with the point at which the:

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