A nurse is assisting with developing a plan of care for a client.

Exhibit 1

Nurses' Notes

2 days ago:

Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.

Today, 0900:

Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.

Complete the following sentence by using the lists of options.

The nurse understands that which of the following dressing should be added to the plan of care Select...

hydrocolloid

dry gauze

hydrogel

alginate

transparent

Answer and Explanation

Correct Answer : A

A. A hydrocolloid dressing is a type of dressing that is used for wounds with minimal exudate, such as the wound on the client's coccyx described in the scenario. It provides a moist environment for wound healing and can help with pain relief. This type of dressing is suitable for wounds with granulation tissue and can help protect the wound from further damage while promoting healing.

B. A dry gauze is not appropriate for this type of wound as it does not provide the necessary moist environment for healing and may adhere to the wound, causing damage upon removal.

C. A hydrogel dressing is typically used for wounds with moderate to heavy exudate.

D. An alginate dressing is typically used for wounds with moderate to heavy exudate. These dressings may not be suitable for the described wound with minimal exudate.

E. A transparent dressing may not be suitable for a wound with granulation tissue and moderate exudate, as it may not provide adequate protection and moisture to the wound.

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Correct Answer is A

Explanation

Rationale:

A. Regular clinical breast examinations by a healthcare provider are recommended for all women, typically starting at age 30, regardless of family history, as part of early detection efforts for breast cancer.

B. While mammograms are important for breast cancer screening, the age at which they should start may vary based on individual risk factors and guidelines from different organizations.

C. Breast ultrasound may be used in specific cases but is not typically recommended as a routine screening tool for breast cancer in asymptomatic women without specific risk factors.

D. Breast self-examinations are important for women to become familiar with their breasts and detect any changes, but the age at which they should start may vary based on individual risk factors and guidelines.

A. Unlock and remove the inner cannula. B. Scrub the inside and outside of the inner cannula with a small brush C. Wipe the inside of the inner cannula with a folded pipe cleaner. D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Correct Answer is A,D,B,C,E

Explanation

A. Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B. Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C. Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.

E. Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.

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A nurse is assisting with developing a plan of care for a client. Exhibit 1

Nurses' Notes

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?

Correct Answer is A

Explanation

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,D,B,C,E

Explanation

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?

A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?

A charge nurse on a long-term care unit is working with an assistive personnel who states, "I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer." Which of the following responses should the charge nurse make?

Nurses' Notes

A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

A nurse is assisting with developing a plan of care for a client.

Exhibit 1