Question

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

Answer 1

Correct Answers:

Client who has swelling and tenderness around the wound

Rationale :

💎 Swelling and tenderness are classic signs of a wound infection due to the inflammatory response to invading pathogens.

💎 Infected wounds often become painful and edematous as white blood cells and fluid accumulate to fight infection.

💎 Other infection signs can include redness, warmth, purulent drainage, and increased local or systemic temperature.

💎 Early recognition allows for prompt treatment, reducing complications such as abscess formation or systemic spread.

💎 Serosanguineous drainage, urticaria (hives), or “bromocriptine over the wound” do not specifically indicate infection.

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Answer 2

Correct Answers:

Respiratory acidosis

Rationale :

🔷 pH 7.33 is low (acidemia), indicating acidosis.

🔷 CO2 of 50 is elevated (normal 35–45 mm Hg), pointing to a respiratory origin for the acidosis.

🔷 HCO3 of 22 is within normal range, so the primary problem is not metabolic.

🔷 Respiratory acidosis occurs when ventilation is inadequate, leading to CO2 retention and decreased blood pH.

🔷 It is commonly caused by hypoventilation, COPD, or severe pneumonia.

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Answer 3

Correct Answers:

Hyperventilation

Rationale :

♦ Respiratory alkalosis occurs when there is excessive loss of CO2 from the lungs, usually due to hyperventilation.

♦ Common triggers include anxiety, pain, fever, or hypoxemia.

♦ The low CO2 raises the blood pH, causing alkalosis.

♦ Symptoms may include dizziness, tingling, and muscle cramps, but hyperventilation is the root cause.

♦ Diarrhea, abdominal pain, and dry skin are not direct manifestations of respiratory alkalosis.

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Answer 4

Correct Answers:

Verify that the patient is giving consent voluntarily.

Rationale :

⬖ The nurse’s role is to ensure that consent is given freely and without coercion. ⬖ This protects patient autonomy and legal rights before surgery. ⬖ The nurse must verify that the patient understands the procedure, alternatives, and risks, but only the provider explains these details. ⬖ If the nurse suspects the patient doesn’t fully understand, the provider should be notified for clarification. ⬖ Ensuring voluntariness upholds ethical and legal standards in healthcare.

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Answer 5

Correct Answers:

Poor nutritional status
Obesity
Nonadherence

Rationale :

🔷 Poor nutritional status impairs wound healing and increases the risk of dehiscence due to lack of essential nutrients for tissue repair.

🔷 Obesity increases pressure on the wound, making separation of the wound edges more likely.

🔷 Nonadherence to wound care or activity restrictions increases mechanical stress or contamination, elevating dehiscence risk.

🔷 Medications (depending on type) and increased metabolic rate may affect healing but are less direct risk factors for dehiscence.

🔷 Recognizing modifiable and nonmodifiable risk factors helps guide prevention and client teaching.

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Answer 6

Correct Answers:

pH 7.31

Rationale :

♦ Respiratory acidosis presents with a pH less than 7.35, indicating acidemia.

♦ pH 7.31 is in the acidotic range, consistent with this disorder.

♦ Higher pH values (7.39, 7.48, 7.50) indicate normal or alkalotic states.

♦ Accurate identification of acid-base status is essential for targeted intervention.

♦ pH reflects the overall acid-base balance and guides urgent management.

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Answer 7

Correct Answers:

Raise the head of the bed.

Rationale :

💎 Raising the head improves chest expansion, ventilation, and oxygenation.

💎 Immediate intervention for low O2 saturation focuses on optimizing respiratory mechanics before other measures.

💎 It is a simple, quick action with no equipment needed and high effectiveness.

💎 Other actions (oxygen therapy, fluids, coughing) are also important but do not provide as rapid an improvement in airway and breathing.

💎 Priority nursing actions always address airway and breathing first

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Answer 8

Correct Answers:

Weakening

Rationale :

🔷 Hyperkalemia (high potassium) causes muscle weakness due to impaired neuromuscular function.

🔷 It may progress to flaccid paralysis if severe and can also cause cardiac dysrhythmias.

🔷 Weakness is an early and common sign; other symptoms include paresthesias and fatigue.

🔷 Decreased DTRs, hyperactive bowel sounds, and cerebral edema are not typical of hyperkalemia.

🔷 Prompt recognition prevents complications, especially cardiac arrest.

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Answer 9

Correct Answers:

Place the patient supine with the knees ﬂexed.

Rationale :

♦ Supine with knees flexed reduces tension on the abdominal muscles and wound, minimizing further dehiscence.

♦ This position also promotes blood flow to vital organs and prepares for emergency intervention if needed.

♦ Covering with a sterile, moist towel is also appropriate but not listed here; clean towel is less ideal.

♦ Applying an abdominal binder or offering fluids are not primary actions for acute dehiscence.

♦ Proper positioning can limit evisceration and further tissue separation.

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Answer 10

Correct Answers:

Spironolactone

Rationale :

💎 Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, especially when combined with other potassium-retaining agents.

💎 It inhibits sodium reabsorption while retaining potassium in the kidneys.

💎 Thiazide (HCTZ), furosemide, and mannitol are not potassium-sparing; they may cause hypokalemia.

💎 Client teaching includes watching for signs of high potassium and regular blood monitoring.

💎 Monitoring potassium prevents life-threatening arrhythmias.

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QLexNursing

1 :
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has manifested a wound infection?

2 :
Based on the ABG results: pH 7.33, CO2: 50, HCO3: 22, what acid-base imbalance is present?

3 :
A nurse is assessing a patient who has respiratory alkalosis. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a patient who is to undergo a total knee arthroplasty. Which of the following actions should the nurse take when participating in the informed consent process?

5 :
A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.

6 :
A nurse is caring for a patient who has respiratory acidosis. Which of the following pH levels should the nurse expect?

7 :
A nurse is caring for a patient who has pneumonia. The patient's oxygen saturation is 85%. Which of the following actions should the nurse take first?

8 :
A nurse is caring for a patient who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

9 :
A nurse is caring for a patient who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 :
When presenting about caring for patients who are receiving diuretic therapy, the nurse should explain that which of the following medications can put patients at risk for hyperkalemia?

QLexNursing

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

2 : Based on the ABG results: pH 7.33, CO2: 50, HCO3: 22, what acid-base imbalance is present?

3 : A nurse is assessing a patient who has respiratory alkalosis. Which of the following findings should the nurse expect?

4 : A nurse is caring for a patient who is to undergo a total knee arthroplasty. Which of the following actions should the nurse take when participating in the informed consent process?

5 : A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.

6 : A nurse is caring for a patient who has respiratory acidosis. Which of the following pH levels should the nurse expect?

7 : A nurse is caring for a patient who has pneumonia. The patient's oxygen saturation is 85%. Which of the following actions should the nurse take first?

8 : A nurse is caring for a patient who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

9 : A nurse is caring for a patient who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 : When presenting about caring for patients who are receiving diuretic therapy, the nurse should explain that which of the following medications can put patients at risk for hyperkalemia?

1 :
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has manifested a wound infection?

2 :
Based on the ABG results: pH 7.33, CO2: 50, HCO3: 22, what acid-base imbalance is present?

3 :
A nurse is assessing a patient who has respiratory alkalosis. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a patient who is to undergo a total knee arthroplasty. Which of the following actions should the nurse take when participating in the informed consent process?

5 :
A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.

6 :
A nurse is caring for a patient who has respiratory acidosis. Which of the following pH levels should the nurse expect?

7 :
A nurse is caring for a patient who has pneumonia. The patient's oxygen saturation is 85%. Which of the following actions should the nurse take first?

8 :
A nurse is caring for a patient who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

9 :
A nurse is caring for a patient who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 :
When presenting about caring for patients who are receiving diuretic therapy, the nurse should explain that which of the following medications can put patients at risk for hyperkalemia?