what is a key nursing action for a client with a wound infection
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What is a key nursing action for a client with a wound infection?

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.

2. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

3. What are the nursing interventions for a patient with hypertension?

Correct answer: A

Rationale: The correct nursing interventions for a patient with hypertension involve monitoring blood pressure and educating the patient about lifestyle changes. These interventions help in managing hypertension by keeping track of the patient's blood pressure readings and empowering them with knowledge to make lifestyle modifications such as adopting a healthy diet, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption. Administering antihypertensive medications (choice B) is typically done by a healthcare provider rather than a nurse. While regular monitoring of blood pressure (choice C) is important, administering diuretics is a specific medical intervention that should be prescribed by a healthcare provider. Monitoring blood glucose (choice D) is more relevant for patients with diabetes rather than hypertension.

4. What are the differences between Type 1 and Type 2 diabetes in terms of treatment?

Correct answer: A

Rationale: The correct answer is A because Type 1 diabetes necessitates insulin therapy, whereas Type 2 diabetes is managed with lifestyle modifications and oral agents. Choice B is incorrect because Type 1 diabetes does not use oral agents as a primary treatment. Choice C is incorrect as it describes the pathophysiology of diabetes types rather than their treatments. Choice D is incorrect because Type 2 diabetes management involves more than just insulin and includes lifestyle changes and oral medications.

5. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

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