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 D

Explanation

Rationale:

A. Small, raised vesicles over the body may indicate an allergic reaction but are not typically associated with IV antibiotics.

B. Rhinitis may indicate an allergic reaction but is not typically associated with IV antibiotics.

C. Itching of the skin may indicate an allergic reaction but is not typically associated with IV antibiotics.

D. Severe wheezing may indicate an allergic reaction or anaphylaxis and should be reported immediately.

A. Avoid the use of facial gestures during the instructions. B. Determine the client's ability to use a communication board. C. Speak with a loud voice while providing the information. D. Provide the teaching without expecting the client to respond.

Correct Answer is B

Explanation

Rationale:

A. Avoiding the use of facial gestures during the instructions may not be effective for a client with expressive aphasia.

B. Determining the client's ability to use a communication board is appropriate because it helps the nurse understand how the client communicates.

C. Speaking with a loud voice while providing the information may not be effective for a client with expressive aphasia.

D. Providing the teaching without expecting the client to respond may not be effective for a client with expressive aphasia.

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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 assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?

Correct Answer is D

Explanation

A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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

Exhibit 1