Question

The client has an open wound on the sacrum with an order for the following: "Apply hydrogel dressing on the wound. Change dressing every day." The nurse recognizes that the primary purpose of this dressing is to:

Answer 1

Correct Answers:

provide moisture to the wound

Rationale :

Hydrogel dressings maintain a moist wound environment, which promotes autolytic debridement and supports cellular migration, enhancing tissue regeneration and wound healing. Keeping the wound moist prevents the wound bed from drying out, reducing pain and minimizing scab formation, which can delay healing.

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Answer 2

Correct Answers:

drug overdose.

Rationale :

Applying both a nitroglycerin patch and an intravenous infusion simultaneously can lead to excessive vasodilation, causing severe hypotension, dizziness, and syncope. Removing the old patch before starting the IV infusion ensures controlled medication levels and prevents unintentional overdose.

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Answer 3

Correct Answers:

drug overdose.

Rationale :

Applying both a nitroglycerin patch and an intravenous infusion simultaneously can lead to excessive vasodilation, causing severe hypotension, dizziness, and syncope. Removing the old patch before starting the IV infusion ensures controlled medication levels and prevents unintentional overdose.

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Answer 4

Correct Answers:

Ineffective breathing pattern.

Rationale :

The client's shallow respirations and reluctance to deep breathe indicate an impaired breathing pattern, which can lead to hypoventilation and inadequate oxygenation. Addressing ineffective breathing patterns early prevents complications such as atelectasis and pneumonia, which can prolong recovery.

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Answer 5

Correct Answers:

restlessness, confusion, tachycardia

Rationale :

Early signs of hypoxia include restlessness and confusion due to decreased oxygen delivery to the brain, while tachycardia occurs as a compensatory mechanism to maintain oxygenation. Recognizing these early symptoms allows for timely intervention to prevent worsening hypoxia and potential respiratory failure.

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Answer 6

Correct Answers:

Diazepam 5 mg PO three times a day

Rationale :

A medication prescribed "three times a day" aligns with a dosing schedule that includes administration at 10:00 AM, 2:00 PM, and 6:00 PM. Understanding standard medication frequencies ensures accurate transcription and administration, preventing dosing errors.

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Answer 7

Correct Answers:

humidifying the oxygen before it is delivered to the client

Rationale :

Oxygen at higher flow rates (≥3 L/min) can dry out the nasal passages and airways, leading to irritation and discomfort. Humidification adds moisture to the oxygen, preventing mucosal dryness and reducing the risk of airway inflammation.

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Answer 8

Correct Answers:

Ventrogluteal

Rationale :

The ventrogluteal site is preferred for intramuscular injections in adults because it has fewer nerves and blood vessels, reducing the risk of injury. This site provides a deep muscle mass, ensuring proper medication absorption and minimizing injection site reactions.

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Answer 9

Correct Answers:

increased carbon dioxide level.

Rationale :

The primary stimulus to breathe in healthy individuals is the accumulation of carbon dioxide, which signals the brain to increase respiratory rate and depth. In conditions like COPD, this drive may be altered, but for most people, CO2 regulation is the main respiratory control mechanism.

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Answer 10

Correct Answers:

increased carbon dioxide level.

Rationale :

The primary stimulus to breathe in healthy individuals is the accumulation of carbon dioxide, which signals the brain to increase respiratory rate and depth. In conditions like COPD, this drive may be altered, but for most people, CO2 regulation is the main respiratory control mechanism.

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RN Fundamentals 100~Exam 4

No.

1 : The client has an open wound on the sacrum with an order for the following: "Apply hydrogel dressing on the wound. Change dressing every day." The nurse recognizes that the primary purpose of this dressing is to:

2 : The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

3 : The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

4 : A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 221minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

5 : The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

6 : The nurse is transcribing a medication order and schedules dosing for 10:00 AM, 2:00 PM and 6:00 PM. Which medication order is consistent with this schedule?

7 : When administering oxygen via a wall-outlet system, the nursing intervention that would be necessary for a 3 L/min flow, as opposed to a 1 L/min flow, would be:

8 : The nurse is to administer a volume of 2 mL intramuscularly (1M) to a 150-pound client.

Assuming that there are no skin problems, which is the preferred site for the injection?

9 : In providing care for clients, the nurse knows that the normal stimulus to breathe is alan:

10 : In providing care for clients, the nurse knows that the normal stimulus to breathe is alan:

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RN Fundamentals 100~Exam 4

No.

1 : The client has an open wound on the sacrum with an order for the following: "Apply hydrogel dressing on the wound. Change dressing every day." The nurse recognizes that the primary purpose of this dressing is to:

2 : The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

3 : The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

4 : A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 221minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

5 : The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

6 : The nurse is transcribing a medication order and schedules dosing for 10:00 AM, 2:00 PM and 6:00 PM. Which medication order is consistent with this schedule?

7 : When administering oxygen via a wall-outlet system, the nursing intervention that would be necessary for a 3 L/min flow, as opposed to a 1 L/min flow, would be:

8 : The nurse is to administer a volume of 2 mL intramuscularly (1M) to a 150-pound client.Assuming that there are no skin problems, which is the preferred site for the injection?

9 : In providing care for clients, the nurse knows that the normal stimulus to breathe is alan:

10 : In providing care for clients, the nurse knows that the normal stimulus to breathe is alan:

8 : The nurse is to administer a volume of 2 mL intramuscularly (1M) to a 150-pound client.

Assuming that there are no skin problems, which is the preferred site for the injection?