a nurse is caring for a client who has a prescription for wound irrigation which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

2. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

3. What is the primary purpose of the Health Insurance Portability and Accountability Act (HIPAA)?

Correct answer: B

Rationale: The primary purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure the confidentiality and security of health information. HIPAA establishes national standards to protect individuals' medical records and other personal health information. By safeguarding the privacy of health data, HIPAA aims to maintain the integrity and confidentiality of sensitive patient information, preventing unauthorized access and disclosure. This focus on privacy and security helps build trust between patients and healthcare providers, ensuring that personal health information is handled responsibly and ethically.

4. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?

Correct answer: D

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.

5. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

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