Question

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

Answer 1

Correct Answers:

Potassium

Rationale :

🟢 Vitamin C (ascorbic acid) plays a crucial role in collagen synthesis, which is essential for wound healing, especially in wounds healing by secondary intention.

🟢 It also supports the immune response and helps reduce the risk of wound infection.

🟢 Protein is needed for tissue regeneration, while Vitamin C enhances tensile strength and tissue integrity.

🟢 Iron and potassium are important nutrients, but they are not directly responsible for wound tissue repair.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

An increase in neutrophils
Localized edema

Rationale :

An increase in neutrophils

🔵 Neutrophils are the body's first responders to infection and will increase during acute bacterial infections, especially in wounds.

🔵 In a client with diabetes and foot pain, a rise in neutrophils may indicate infection in the affected tissue, possibly due to impaired wound healing.

🔵 Neutrophilia is a hallmark lab sign of localized or systemic infection.

Localized edema

🔵 Swelling is a common sign of inflammation and infection, indicating an immune response in the area.

🔵 In clients with diabetes, even minor trauma to the feet can lead to serious infections, often accompanied by redness, heat, and swelling.

🔵 Localized edema should prompt further assessment for possible cellulitis or abscess formation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Diaphoresis

Rationale :

🟡 Diaphoresis (excessive sweating) is a classic symptom of hypoglycemia, caused by activation of the sympathetic nervous system.

🟡 Other signs include shakiness, irritability, hunger, tachycardia, and pallor.

🟡 In contrast, fruity breath odor, dry mucous membranes, and polyuria are signs of hyperglycemia or diabetic ketoacidosis (DKA).

🟡 Recognizing early hypoglycemia helps prevent seizures or unconsciousness.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"Splint your incision with a pillow when coughing."

Rationale :

🟠 Splinting the incision with a pillow supports the abdominal wall, helping reduce pain and wound dehiscence during coughing.

🟠 This technique is essential in post-abdominal surgery to protect the surgical site and maintain client comfort.

🟠 The client should be taught to inhale through the nose during deep breathing, not the mouth.

🟠 Coughing and deep breathing should be performed every 1–2 hours, not just every 4 hours.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Laceration

Rationale :

🔴 A laceration is a wound characterized by torn skin and underlying tissue, often caused by blunt or shearing trauma like an explosion.

🔴 These wounds may have irregular or jagged edges, and the underlying tissue may be exposed or damaged.

🔴 A contusion is a bruise with no break in the skin, an abrasion involves superficial scraping, and a puncture is a narrow, deep wound like a stab or bite.

🔴 Correctly identifying wound type is vital for accurate reporting and proper treatment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Partial-thickness skin loss with red tissue in the wound bed.

Rationale :

🔷 A stage 2 pressure injury involves partial-thickness skin loss, which affects the epidermis and possibly the dermis.

🔷 The wound bed is often red, moist, and may appear like a ruptured blister.

🔷 There is no slough, eschar, or exposed structures, and the injury is shallow.

🔷 It differs from Stage 1 (intact skin) and Stages 3/4 (full-thickness skin loss).

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Pneumonia

Rationale :

♦️ Dysphagia increases the risk of aspiration, where food or fluids enter the lungs instead of the stomach.

♦️ This can result in aspiration pneumonia, a serious complication in clients with impaired swallowing.

♦️ Monitoring includes watching for coughing during meals, abnormal lung sounds, and fever.

♦️ Preventive measures include positioning upright and modifying food consistency.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Change the feeding bag every 24 hr.

Rationale :

💠 To prevent bacterial growth and infection, enteral feeding bags should be changed every 24 hours.

💠 Flushing should be done with water, not sodium chloride, unless otherwise prescribed.

💠 The head of the bed should be at 30–45°, not 15°, to prevent aspiration.

💠 Gastric residuals are generally checked every 4 hours in continuous feedings unless ordered otherwise.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

IV insertion site

Rationale :

🔹 Clients receiving TPN (total parenteral nutrition) are at high risk for infection and infiltration at the central line or IV site.

🔹 Monitoring the site for signs of erythema, swelling, discharge, or pain is essential to catch sepsis or phlebitis early.

🔹 TPN is a hypertonic solution and can damage tissue if extravasation occurs.

🔹 Hypoglycemia can occur, but infection is the most critical and frequent concern.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"Inhale through the incentive spirometer 10 times with each use."

Rationale :

🔶 Incentive spirometry is used to encourage deep lung expansion and prevent atelectasis postoperatively.

🔶 The client should inhale slowly through the device 10 times per session, ideally every hour while awake.

🔶 The client should sit upright at least 45–90° to maximize diaphragm movement.

🔶 Holding the breath for 3–5 seconds is typical; 7 seconds may be excessive.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

2 :
A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

3 :
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

4 :
A nurse is reinforcing teaching with a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?

5 :
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

6 :
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

8 :
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

9 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

10 :
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

QLexNursing

1 : A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

2 : A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

3 : A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

4 : A nurse is reinforcing teaching with a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?

5 : A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

6 : A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

7 : A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

8 : A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

9 : A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

10 : A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

1 :
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

2 :
A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

3 :
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

4 :
A nurse is reinforcing teaching with a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?

5 :
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

6 :
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

8 :
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

9 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

10 :
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?