A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A client who has swelling and tenderness around the wound

A client who has brown crusting over the wound

A client who has serosanguineous drainage from the wound

A client who has urticaria and itching around the wound

Answer and Explanation

The Correct Answer is A

A.   Swelling and tenderness around the wound are common signs of infection, indicating an inflammatory response to the presence of bacteria.
B.   Brown crusting over the wound may suggest the presence of a scab or dried exudate, which is a normal part of the healing process and not necessarily indicative of infection.
C.   Serosanguineous drainage is a type of wound drainage that is typically not a sign of infection but rather a mix of clear and blood-tinged fluid.
D.   Urticaria and itching around the wound suggest an allergic reaction rather than a wound infection.

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

Explanation

A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

A. Standards of care published by the Oncology Nursing Society B. Recommendations from a nurse who has worked in an outpatient chemotherapy clinic C. A qualitative study exploring clients’ perspectives on receiving chemotherapy D. A chapter on chemotherapy in a published textbook

Correct Answer is A

Explanation

A. Standards of care published by reputable organizations, such as the Oncology Nursing Society, provide evidence-based guidelines and best practices.
B. While the experience of a nurse in a chemotherapy clinic is valuable, it may not represent standardized, evidence-based practices.
C. A qualitative study may provide insights into clients' perspectives but may not necessarily offer specific interventions for oral care.
D. Published textbooks can be valuable resources, but standards of care from professional organizations are generally more up-to-date and evidence-based.

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A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is contributing to the development of an oral care protocol for clients who are receiving chemotherapy. Which of the following resources should the nurse utilize to identify interventions?

Correct Answer is A

Explanation

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using?

A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?

A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

A nurse is participating in a staff discussion about disaster triage. The nurse should include which of the following clients as an example emergent (red tag) category?

A nurse in a clinic is collecting data from an older adult client who has a new diagnosis of osteoarthritis. Which of the following medications should the nurse anticipate the provider will initially prescribe to the client?

A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?