Question

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Answer 1

Correct Answers:

Neutrophil count.

Rationale :

🧪The presence of purulent drainage in a client with extensive full-thickness burns suggests a possible wound infection, and the neutrophil count is a key marker of the body’s immune response to infection.

🦠An elevated or decreased neutrophil count helps determine whether the body is effectively fighting infection or if neutropenia might be impairing defense.

💉While serum albumin reflects nutritional status and healing potential, it is not directly useful in assessing an acute infection.

🍬Serum blood glucose may rise with stress or infection but is not as specific as neutrophil count for determining infection status.

🩸Hematocrit reflects fluid balance or blood loss but does not provide direct information on immune function or infection presence.

📌Core Message

The neutrophil count is the most relevant lab to assess for infection in burn clients with purulent drainage.

Answer 2

Correct Answers:

Include no more than 1-2 alcoholic beverages in diet per day

Rationale :

🍷For clients with type 2 diabetes mellitus, moderate alcohol consumption (no more than 1 drink per day for women and 2 for men) may be acceptable if blood glucose is well controlled and with food to avoid hypoglycemia.

📉Alcohol can lower blood glucose, especially when consumed on an empty stomach, so moderation and timing are essential to prevent hypoglycemic episodes.

🔥Soaking feet in hot water is unsafe due to neuropathy risks and the potential for burns or skin damage.

🏃Stating that exercise does not affect blood glucose is false—physical activity lowers glucose levels and improves insulin sensitivity.

🩹Keeping wounds covered is appropriate, but self-treatment with antibiotic ointments without provider evaluation can mask infection or delay necessary care in diabetic clients.

📌Core Message

Moderate alcohol intake (1–2 drinks/day) can be safe for type 2 diabetes when consumed with food and under glucose control.

Answer 3

Correct Answers:

Leave the client's room and return later in the day.

Rationale :

🧍‍♀️A client who responds with anger or avoidance after a new type 1 diabetes diagnosis may be exhibiting signs of the grieving process, such as denial or anger, which are common early emotional reactions.

🕒Respecting the client’s emotional space by leaving and returning later demonstrates therapeutic communication and preserves trust, while allowing time to process difficult news.

🧠Immediately pushing teaching or stressing the life-saving importance of insulin may be overwhelming and increase resistance.

🗣️Suggesting relaxation techniques or referring to a social worker may be helpful later, but in the moment of intense emotion, the priority is to support the client’s autonomy and provide emotional space.

📌Core Message

When faced with emotional resistance, the nurse should respect the client’s space and return later to support effective teaching and emotional readiness.

Answer 4

Correct Answers:

Right foot is cool to the touch and appears pale and blanched.

Rationale :

🦶A cool, pale, or blanched extremity is a classic sign of arterial obstruction, indicating impaired blood flow distal to the catheter insertion site—in this case, the right femoral artery.

🔎This assessment suggests ischemia, which requires immediate intervention to restore perfusion and prevent tissue damage or limb loss.

🩹While oozing blood from the pressure dressing signals bleeding, it doesn’t necessarily confirm arterial obstruction.

📉A weaker pulse on the left foot (non-catheterized side) is not relevant to detecting obstruction in the right femoral artery.

🧡Hypotension and irregular heart rate may indicate systemic compromise but are less specific than localized signs for identifying an arterial blockage.

📌Core Message

A cool, pale extremity indicates arterial obstruction and requires urgent vascular assessment after cardiac catheterization.

Answer 5

Correct Answers:

Notify information services department of the situation.

Rationale :

📞The first action when a computer documentation system fails to restart is to immediately notify the information services (IT) department, who are responsible for system maintenance and troubleshooting.

💻Prompt notification allows the appropriate personnel to investigate and resolve the issue quickly, minimizing disruption to clinical care and documentation.

🖨️Attempting to print from a backup server is not feasible until IT evaluates the system status and grants access; this is not an initial nursing responsibility.

⏳Waiting passively delays resolution and increases the risk of gaps in documentation.

📝Marking information as a late entry is appropriate after the system is restored, but it’s not the first step when the system fails.

📌Core Message

The nurse should first notify information services to address the documentation system failure and begin recovery.

Answer 6

Correct Answers:

Keep head of bed raised 45 degrees.

Rationale :

🛏️Raising the head of the bed to 45 degrees is important in septic shock to improve oxygenation, especially if the client is experiencing respiratory distress or pulmonary involvement, which is common in sepsis-related complications like ARDS.

🌬️Elevating the head facilitates lung expansion, reduces the risk of aspiration, and helps improve ventilation-perfusion matching, which supports oxygen delivery to tissues—a critical goal in sepsis care.

💧While intake and output monitoring is important for evaluating perfusion and kidney function, airway and breathing take priority under the ABCs of critical care.

🧪Monitoring glucose or extremity warmth are supportive assessments but do not directly address oxygenation, which is a more urgent physiologic need in sepsis with suspected shock.

📌Core Message

In septic shock, elevating the head of bed helps improve oxygenation and respiratory function, a priority intervention in early management.

Answer 7

Correct Answers:

Increasing confusion of the client.

Rationale :

🟠Increasing confusion represents the immediate clinical concern and reflects the “Situation” component of the SBAR framework, which is always communicated first to ensure clarity about the current, urgent issue.

🟡The SBAR method is structured to prioritize the current problem first, followed by relevant background, assessment, and then a recommendation to guide timely medical decision-making.

🔵In this case, a sudden change in mental status could indicate a serious complication such as a fat embolism, which is a potential risk following an ORIF of a long bone like the femur.

🟣Delaying the report of the acute change in mental status to provide background details first could hinder prompt evaluation and treatment, putting the client at risk for deterioration.

📌Core Message

Report the most urgent clinical issue first using SBAR by beginning with the current situation to facilitate prompt provider response.

Answer 8

Correct Answers:

B. Check femoral site for hematoma formation.

Rationale :

🔴Pain at the groin site following a cardiac catheterization is a red flag for hematoma or bleeding at the insertion point, especially when anticoagulants like heparin are in use.

🧲Hematoma formation can lead to serious complications, including compromised circulation, and must be assessed first before any further interventions are taken.

👀While checking distal capillary refill is appropriate for circulation monitoring, it does not address the primary complaint of localized groin pain, which could indicate active bleeding.

💉Actions like checking the IV site or encouraging deep breathing do not address the urgent vascular concern at the femoral access site, making them less immediately relevant.

📌Core Message

Always assess the catheter insertion site first when there is pain or bleeding risk, especially following cardiac catheterization with anticoagulant therapy.

Answer 9

Correct Answers:

Immunizations that are available.

Rationale :

🧪Primary prevention aims to prevent disease before it occurs, and immunizations are one of the most effective and widely used methods to achieve this goal.

📆Vaccinations help the body develop adaptive immunity to prevent the onset of infectious diseases, which aligns directly with primary prevention strategies.

🔍Options like blood pressure screening fall under secondary prevention because they involve early detection of disease, while support groups and violence assistance represent tertiary prevention to manage or cope with existing problems.

📚Educating the public about available immunizations helps reduce the incidence of communicable diseases and promotes community-wide health protection.

📌Core Message

Primary prevention focuses on stopping disease before it starts, and immunizations are a key strategy in this level of prevention.

Answer 10

Correct Answers:

Apply sequential compression stockings.

Rationale :

🔺Gastroplasty candidates are often obese and at increased risk for venous thromboembolism (VTE), particularly during the postoperative period, making VTE prophylaxis a top priority.

🧦Applying sequential compression stockings promotes venous return, reducing the risk of deep vein thrombosis (DVT) and pulmonary embolism, which are life-threatening complications.

🔄Although monitoring for depression or urinary issues may be relevant in long-term care, they do not take precedence in the immediate perioperative setting where circulatory stability is critical.

🍽️Offering a wide variety of meals is inappropriate post-gastroplasty, as clients require strict dietary control and gradual progression of intake, not variety.

📌Core Message

Preventing thromboembolism is a top priority after bariatric surgery, and sequential compression devices are essential for circulatory protection in obese postoperative clients.

1 :
While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

2 :
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

3 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 :
The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 :
After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 :
The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

1 : While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

2 : The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

3 : When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 : The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 : After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 : The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 : The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

1 :
While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

2 :
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

3 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 :
The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 :
After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 :
The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?