the nurse is examining a patients lower leg and notices a draining ulceration which of these actions is most appropriate in this situation the nurse is examining a patients lower leg and notices a draining ulceration which of these actions is most appropriate in this situation
Logo

Nursing Elites

NCLEX NCLEX-RN

NCLEX RN Exam Preview Answers

1. During an examination, a nurse notices a draining ulceration on a patient’s lower leg. What is the most appropriate action in this situation?

Correct answer: C: Wash hands, put on gloves, and continue with the examination of the ulceration.

Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.

2. A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?

Correct answer: Performing range of motion exercises

Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.

3. An 80-year-old patient is admitted with dyspnea, dependent edema, rales, and distended neck veins. As the nurse monitors the patient, he becomes increasingly short of breath and begins to have cardiac dysrhythmias. The most critical intervention for this patient is to:

Correct answer: Ensure his airway is open and unobstructed.

Rationale: In a patient presenting with dyspnea, dependent edema, rales, distended neck veins, and developing cardiac dysrhythmias, the priority intervention is to ensure the airway is open and unobstructed. Maintaining an open airway is crucial for adequate ventilation and oxygenation, especially in a patient showing signs of impending respiratory distress and cardiac compromise. While applying oxygen to maintain oxygen saturation is important, ensuring airway patency takes precedence as it directly impacts the patient's ability to breathe. Administering Dobutamine may be necessary to improve cardiac output; however, addressing the airway first is essential to prevent further respiratory distress and worsening dysrhythmias. Starting an IV for monitoring fluid intake is not the most critical intervention in this scenario compared to ensuring airway patency and oxygenation.

4. A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?

Correct answer: A restricted sodium diet

Rationale: For a patient with Addison’s disease, a restricted sodium diet is not recommended. These patients require normal dietary sodium to prevent excess fluid loss. Patients with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Therefore, a diet high in grains, a diet with adequate caloric intake, and a high protein diet are all recommended for patients with Addison's disease to support their nutritional needs and overall health. However, restricting sodium can be detrimental for these patients due to the nature of their condition.

5. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating, “the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society,” reflects which term?

Correct answer: Culture

Rationale: The term that best fits the provided definition, which includes knowledge, beliefs, customs, and skills acquired by members of a society, is 'Culture.' Culture is a broad concept encompassing various aspects of a society's way of life. Norms refer to typical behaviors or rules within a society. Ethnicity pertains to shared traits among a social group, such as origin, religion, language, and traditions. Assimilation involves adopting the dominant culture's characteristics, often through integration or conformity.

Similar Questions

The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care?
The parents of a child often try to persuade their preschooler to touch their pet dog to reduce the child’s fear of dogs. Instead, the child’s fears and anxiety increase. Which advice would the nurse suggest to help overcome their child’s fear?
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
A systolic blood pressure of 145 mm Hg is classified as:
A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99