the nurse is caring for a client with a wound infection which type of dressing is most appropriate to use to promote healing by secondary intention
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HESI LPN

HESI Fundamentals Exam Test Bank

1. The healthcare provider is caring for a client with a wound infection. Which type of dressing is most appropriate to use to promote healing by secondary intention?

Correct answer: D

Rationale: Hydrocolloid dressings are ideal for promoting healing by secondary intention in wound infections. These dressings create a moist environment that supports autolytic debridement and facilitates the healing process. Dry gauze dressings (Option A) may lead to adherence, causing trauma upon removal and disrupting the wound bed. Wet-to-dry dressings (Option B) are primarily used for mechanical debridement and can be painful during dressing changes. Transparent film dressings (Option C) are more suitable for superficial wounds with minimal exudate and are not typically used for wound infections requiring healing by secondary intention.

2. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.

3. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

4. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

5. When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?

Correct answer: B

Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.

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