Question

A nurse is caring for a client in a wound center.

Answer 1

Correct Highlights :

Left knee wound is 3 cm by 2 cm with 1 cm depth. Wound bed vascular with some approximation of the edges
Client rates pain as 8 on a scale of 0 to 10 in their left knee.
Temperature 38.6°C (101.4°F)
Heart rate 104/min

Rationale :

✅ Increasing wound size (from 2 × 2 cm to 3 × 2 cm)

🔶 Wound vac therapy should promote shrinkage and granulation; enlargement indicates poor healing.

🔶 Increased wound dimensions suggest the wound environment is not optimized for repair.

🔶 A wound that grows over time can indicate infection or inadequate suction.

🔶 Healing progression is measured by consistent reduction in size, which did not occur.

🔶 Size increase signals the need to reassess the treatment plan.

✅ Increased pain from 4/10 to 8/10 with no relief from medication

🔶 Rising pain often reflects worsening inflammation or infection in the wound bed.

🔶 Lack of relief with medication indicates progression rather than expected postoperative discomfort.

🔶 Pain that intensifies a week after surgery is abnormal and concerning.

🔶 Pain escalation often precedes visible infection signs.

🔶 This trend should prompt immediate reassessment of wound integrity and therapy effectiveness.

✅ Development of purulent drainage

🔶 Purulent drainage indicates infection, which contradicts the expected outcomes of wound vac therapy.

🔶 Infection prevents wound contraction and granulation, delaying healing.

🔶 Wound vacs should reduce exudate and bacterial load, not worsen it.

🔶 Purulence signals bacterial activity overwhelming wound defenses.

🔶 This is one of the most definitive signs that therapy is unsuccessful.

✅ Temperature increase from 37.1°C → 38.6°C

🔶 Fever indicates systemic response to infection, commonly originating from the wound site.

🔶 Wound vac therapy should reduce bioburden; systemic infection shows the opposite trend.

🔶 Rising temperature aligns with the presence of purulence and uncontrolled wound inflammation.

🔶 This finding requires immediate provider notification.

🔶 Fever plus local signs confirm therapy failure.

✅ Heart rate increase from 94 → 104/min

🔶 Tachycardia is a physiologic sign of infection or uncontrolled pain.

🔶 Increased heart rate is consistent with systemic inflammatory response syndrome (SIRS).

🔶 A rising pulse in a post-surgical client indicates deteriorating status, not improvement.

🔶 Wound vac therapy should stabilize or improve vitals, not worsen them.

🔶 This change supports the pattern of infection.

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Answer 2

Correct Answers:

Reposition the client every 3 hr.
Request a consult with a registered dietitian.
Provide a support pressure-redistribution surface.
Use a moisture barrier ointment after cleaning the client's skin.

Rationale :

🟩 Reposition the client every 3 hr. The client has impaired mobility and incontinence, placing them at high risk for pressure injuries, making scheduled repositioning essential.

🟩 Changing positions regularly reduces prolonged pressure on bony prominences.

🟩 This helps maintain skin integrity in clients with sensory deficits such as diabetic neuropathy.

🟩 Request a consult with a registered dietitian. Adequate nutrition is vital for skin integrity and healing, especially in clients at risk for pressure injuries.

🟩 A dietitian can assess for protein or caloric deficits that may contribute to skin breakdown.

🟩 Early nutritional intervention supports prevention of further complications.

🟩 Provide a support pressure-redistribution surface Clients with limited mobility benefit from specialized mattresses or overlays that reduce pressure intensity.

🟩 These surfaces help distribute body weight more evenly, protecting vulnerable skin areas.

🟩 This intervention reduces the likelihood of pressure injury development in high-risk clients.

🟩 Use a moisture barrier ointment after cleaning the client's skin. Frequent loose stools place the client at risk for moisture-associated skin damage.

🟩 Moisture barriers protect the skin from irritants and breakdown caused by incontinence.

🟩 Protecting the perineal area helps prevent dermatitis and secondary infection.

Place the client on a donut-shaped cushion.

🟩 Donut cushions increase pressure on surrounding tissue and can worsen skin breakdown.

🟩 They are not recommended for pressure injury prevention.

Elevate the head of the bed to 45°.

🟩 Higher bed elevation increases shear and friction injury risk, especially in clients with decreasedsensation.

🟩 Lower angles are preferred unless medically required.

Perform a skin risk assessment weekly.

🟩 High-risk clients require daily skin checks and routine reassessment, not weekly evaluation.

🟩 Weekly assessment delays early detection of skin changes.

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Answer 3

Correct Answers

Blank 1 Correct Option: oxygen saturation
Blank 2 Correct Option: behavioral findings

Rationale :

🟧 The client’s oxygen saturation dropped from 95% to 90%, which is a clinically significant decline and can indicate early postoperative hypoxemia or developing respiratory compromise.

🟧 Low oxygen saturation always takes priority because oxygenation is essential for tissue perfusion, especially in a post-operative client with recent major blood loss.

🟧 The client’s behavioral change—agitation and stating “I feel like something is wrong”—is an early sign of hypoxia and should not be dismissed.

🟧 Behavioral changes often precede vital sign deterioration and may reflect inadequate oxygen delivery to the brain.

🟧 Combining the drop in oxygen saturation with behavioral changes suggests an acute physiologic issue that requires immediate nursing intervention, such as increasing oxygen, performing airway assessment, and notifying the provider.

pain

🟧 Pain rating of 5/10 is expected postoperatively and does not explain the agitation or oxygenation decline.

🟧 Pain is not the priority over respiratory compromise.

WBC count

🟧 WBC is only slightly elevated and does not require immediate follow-up in the acute postoperative period.

🟧 It does not explain the sudden behavioral changes.

bowel findings

🟧 Hypoactive bowel sounds are expected after abdominal surgery.

🟧 This is not an emergent finding.

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Answer 4

Correct Answers:

Request a prescription for an antiemetic medication.
Place the client on contact precautions.
Clarify the prescription for amoxicillin with the provider.

Rationale :

🔷 Request a prescription for an antiemetic medication The client reports nausea and poor intake, which may worsen hydration status and delay recovery from the infection.

🔷 Supporting comfort and adequate nutrition is essential because inadequate intake can impair immune response.

🔷 Requesting an antiemetic is an appropriate nursing action to promote symptom control and improve tolerance of oral medications.

🔷 Place the client on contact precautions. By Day 3, the client has developed multiple loose stools, raising concern for Clostridioides difficile infection, especially after receiving antibiotics.

🔷 Contact precautions help prevent transmission of diarrhea-associated pathogens to other clients and staff.

🔷 This is a safety-focused intervention until the cause of diarrhea is ruled out.

🔷 Clarify the prescription for amoxicillin with the provider. The client has a documented allergy to penicillin, and amoxicillin is a penicillin-class antibiotic that may cause an allergic reaction.

🔷 Administering this medication without clarification places the client at risk for hypersensitivity or anaphylaxis.

🔷 The nurse must verify a safe alternative before giving any penicillin-related drug.

Hold the dose of levothyroxine.

🔷 There is no indication of adverse effects or contraindications to levothyroxine in the current assessment.

🔷 This medication should not be held unless parameters or symptoms warrant it.

Ensure the client wears a surgical mask outside their room.

🔷 Surgical masks are required for airborne or droplet precautions, not for contact precautionsrelated to suspected C. difficile.

🔷 The client’s symptoms do not indicate a respiratory infection requiring masking.

Recommend increasing the dose of metoprolol.

🔷 The client’s blood pressure and heart rate are stable and do not suggest a need for increasedantihypertensive therapy.

🔷 Adjusting the dose without clinical justification could lead to hypotension or bradycardia.

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Answer 5

Correct Answers:

Administer supplemental oxygen.
Ambulate the client 30 min after administering analgesia.
Instruct the client to use the incentive spirometer five times per hour.
Encourage the client to cough and breathe deeply.
Encourage the client to splint the abdomen.

Rationale :

🟦 Administer supplemental oxygen. The client’s oxygen saturation has declined to 92%, indicating impaired respiratory effort and reduced alveolar ventilation.

🟦 Supplemental oxygen helps improve oxygenation while addressing underlying postoperative hypoventilation.

🟦 This intervention supports respiratory status until lung expansion improves.

🟦 Ambulate the client 30 min after administering analgesia. Ambulation enhances lung expansion and prevents postoperative atelectasis, especially crucial with diminished breath sounds and crackles.

🟦 Administering analgesia first reduces pain, making movement more tolerable and safer.

🟦 Early mobilization improves ventilation and overall respiratory function.

🟦 Instruct the client to use the incentive spirometer five times per hour.Incentive spirometry promotes deep inspiration, improving alveolar inflation and preventing atelectasis.

🟦 The client's shallow respirations and crackles show a need for lung recruitment exercises.

🟦 Frequent use improves oxygenation and reduces postoperative pulmonary complications.

🟦 Encourage the client to cough and breathe deeply. Deep breathing improves ventilation and helps mobilize trapped air in the lower lobes where crackles are present.

🟦 Coughing aids in clearing secretions that may worsen gas exchange.

🟦 These exercises are essential after abdominal surgery to prevent pneumonia.

🟦 Encourage the client to splint the abdomen. Splinting reduces incisional pain during coughing and deep breathing, making respiratory exercises more effective.

🟦 It increases cooperation because the client feels more secure during movement.

🟦 This promotes adequate ventilation while protecting the surgical site.

Administer acetaminophen.

🟦 The client does not have a fever that requires acetaminophen at this time.

🟦 Acetaminophen does not improve respiratory status and is unrelated to the current problem.

Administer ondansetron.

🟦 The client reports no nausea at 1000.

🟦 Treating nausea does not promote respiratory status in this scenario.

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Answer 6

Correct Answers:

Don a gown when entering the client's room.
Provide a mask for the client when they are, outside their room.
When removing personal protective equipment, remove gloves first.

Rationale :

🟩 Don a gown when entering the client's room. Clostridium difficile requires contact precautions, which includes wearing gloves and a gown to prevent spore transmission.

🟩 The client also has influenza, which adds a droplet precaution layer, but contact precautions still mandate a gown.

🟩 This action prevents contamination of clothing and reduces the risk of spreading infection to others.

🟩 Provide a mask for the client when they are outside their room. Influenza is transmitted through respiratory droplets, so the client must wear a mask if they leave the room.

🟩 Wearing a mask prevents droplets from spreading into the environment and exposing other vulnerable clients.

🟩 This measure is essential anytime a droplet-precaution client moves outside their controlled room environment.

🟩 When removing personal protective equipment, remove gloves first. Gloves are the most contaminated part of PPE when caring for a client with C. difficile and influenza.

🟩 Removing gloves first reduces the chance of contaminating other PPE or clean areas of the body.

🟩 This follows standard CDC PPE removal sequence for infection control.

Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room.

🟩 Alcohol-based sanitizer does not kill C. difficile spores.

🟩 Handwashing with soap and water is required after caring for this client.

Place the client in a room with positive air flow.

🟩 Positive airflow rooms push air out, which increases the spread risk of influenza.

🟩 Droplet and contact precautions do not require positive-pressure rooms.

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Answer 7

Correct Answers

Blank 1 Correct Option: infection
Blank 2 Correct Option: thrombophlebitis

Rationale :

🟨 The presence of purulent drainage at the IV site indicates that bacteria have entered the catheter pathway and surrounding tissue, showing that the client has developed an infection.

🟨 The client’s elevated temperature and localized inflammation support the diagnosis of an infection originating from the catheter site.

🟨 The red streak along the vein with a palpable cord is a hallmark manifestation of thrombophlebitis and results from inflammation of the vein wall.

🟨 Warmth, tenderness, and pain at the IV site further reinforce the presence of inflammation consistent with thrombophlebitis.

🟨 These two conditions often occur together when an infected IV site causes irritation and inflammatory damage to the vein.

Circulatory overload

🟨 This condition presents with respiratory distress, crackles, and hypertension rather than localized IV site pain and drainage.

🟨 No findings indicate excessive fluid accumulation.

Extravasation

🟨 Extravasation is characterized by blistering and severe tissue damage from vesicant medications, not red streaking or purulent drainage.

🟨 The hallmark is fluid leaking into tissue, which is not described here.

Phlebitis

🟨 Phlebitis includes pain and redness but does not involve purulent drainage or fever.

🟨 The presence of infection elevates the diagnosis to thrombophlebitis rather than simple phlebitis.

Infiltration

🟨 Infiltration presents with cool, pale skin and swelling caused by IV fluid entering surrounding tissue.

🟨 The client has warmth and red streaking instead, ruling out infiltration.

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Answer 8

Correct Answers:

"You should follow a balanced intake of carbohydrates, fats, and proteins."

Rationale :

🟪 Teaching about a balanced macronutrient intake is the priority because stable carbohydrate distribution directly affects blood glucose control.

🟪 Clients with type 2 diabetes must understand how carbohydrates influence post-meal glycemic spikes to prevent hyperglycemia.

🟪 Including appropriate amounts of protein and healthy fats supports steady energy levels and improves satiety, reducing glucose fluctuations.

🟪 A balanced diet also reinforces how meal planning contributes to long-term glucose management and reduces the need for medication adjustments.

🟪 Prioritizing foundational dietary teaching ensures the client can safely plan meals that maintain stable blood glucose throughout the day.

"You should follow a diet high in vegetables, fiber, and uncooked fruit."

🟪 This is helpful advice but not the first priority because it does not address carbohydrate regulation essential for early diabetes education.

🟪 It expands on healthy choices rather than focusing on core glucose-management principles.

"You should follow a low sodium diet."

🟪 While beneficial for cardiovascular health, sodium intake does not directly influence glycemic control.

🟪 It is supportive teaching but not the primary dietary concept for diabetes management.

"You should follow a low cholesterol diet."

🟪 Lipid control is important for long-term vascular complications, but it does not immediately help stabilize blood glucose.

🟪 This teaching becomes relevant after the client understands how to control carbohydrate intake.

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Answer 9

Correct Answers:

Clear liquids

Rationale :

🟥 A clear liquid diet is unsafe for a client with dysphagia because thin liquids greatly increase the risk of aspiration.

🟥 Clients with swallowing difficulty require thickened liquids or modified textures that allow better control in the mouth and throat.

🟥 Aspiration of thin liquids can quickly lead to pneumonia, airway obstruction, or respiratory decline.

🟥 Clarifying the prescription prevents the nurse from administering a diet that poses an immediate safety threat.

🟥 Dysphagia management always prioritizes airway protection, making inappropriate diet orders the highest concern.

Speech therapy referral

🟥 Speech therapy is essential for evaluating swallow function and helping determine safe textures.

🟥 This prescription is appropriate for dysphagia.

Dietitian consult

🟥 A dietitian is needed to help plan nutritional modifications based on the client’s swallowing ability.

🟥 This order supports safe nutrition and does not require clarification.

Oral suction at the bedside

🟥 Suctioning equipment is appropriate because clients with dysphagia can accumulate oral secretions.

🟥 This prescription increases airway safety and should not be questioned.

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Answer 10

Correct Answers:

Tie the linens' bag securely at the top.

Rationale :

🟫 Tying the linen bag securely prevents microorganisms from escaping and contaminating the hallway or other surfaces.

🟫 Properly securing the bag maintains containment of contaminated materials, which is essential for contact precautions.

🟫 This reduces the risk of spreading pathogens through handling or transport of soiled linens.

🟫 Containment is the priority action because it minimizes cross-contamination to staff and other clients.

🟫 This practice follows standard infection-control procedures for laundry handling in healthcare settings.

Double-bag the linens.

🟫 Double-bagging is only required if the outside of the first bag becomes contaminated.

🟫 It is not routine practice for contact precautions.

Wear sterile gloves when handling the linens.

🟫 Sterile gloves are unnecessary for linen removal because clean gloves provide adequate protection.

🟫 Sterile technique is reserved for procedures that require asepsis.

Rinse the linens prior to removing them from the client's room.

🟫 Rinsing linens increases risk of splashing and environmental contamination.

🟫 Linens should be placed directly into a designated bag without pre-cleaning.

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QLexNursing

1 :
A nurse is caring for a client in a wound center.

Correct Highlights :

2 :
A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 :
A nurse is caring for a client on a medical surgical unit.

Correct Answers

4 :
A nurse is caring for a client who has a urinary tract infection.

Answer Options

5 :
Client is 1 day postoperative following an open appendectomy.

Answer Options

6 :
A nurse is caring for a client on a medical-surgical unit.

Answer Options

7 :
A nurse is caring for a client who is receiving continuous IV therapy.

Correct Answers

8 :
A nurse is providing teaching for a client who has a recent diagnosis of type 2 diabetes mellitus. Which of the following information should the nurse prioritize in the teaching for a diabetic diet?

9 :
A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

10 :
A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?

QLexNursing

1 : A nurse is caring for a client in a wound center.

Correct Highlights :

2 : A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 : A nurse is caring for a client on a medical surgical unit.

Correct Answers

4 : A nurse is caring for a client who has a urinary tract infection.

Answer Options

5 : Client is 1 day postoperative following an open appendectomy.

Answer Options

6 : A nurse is caring for a client on a medical-surgical unit.

Answer Options

7 : A nurse is caring for a client who is receiving continuous IV therapy.

Correct Answers

8 : A nurse is providing teaching for a client who has a recent diagnosis of type 2 diabetes mellitus. Which of the following information should the nurse prioritize in the teaching for a diabetic diet?

9 : A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

10 : A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?

1 :
A nurse is caring for a client in a wound center.

2 :
A nurse is caring for a client on a medical-surgical unit.

3 :
A nurse is caring for a client on a medical surgical unit.

4 :
A nurse is caring for a client who has a urinary tract infection.

5 :
Client is 1 day postoperative following an open appendectomy.

6 :
A nurse is caring for a client on a medical-surgical unit.

7 :
A nurse is caring for a client who is receiving continuous IV therapy.

8 :
A nurse is providing teaching for a client who has a recent diagnosis of type 2 diabetes mellitus. Which of the following information should the nurse prioritize in the teaching for a diabetic diet?

9 :
A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

10 :
A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?