A nurse is assessment pressure ulcers on four clients to evaluate the effectiveness

of a change in the wound care procedure. Which of the following findings indicate

wound healing.

a. erythema on the skin surrounding a client's wound

b. deep red color on the center of the client's wound

c. inflammation noted on the tissue edges of a client's wound

d. increase in serosanguineous exudate from the client's wound

(ANS- b. deep red color on the center of the client's wound

A nurse receiving change of shift report at 0700 for four clients. which of the

following actions should the nurse perform first?

a. obtain a breakfast tray for a client who receiving a morning dose of insulin

aspart

b. administer pain medication to a client who has rheumatoid arthritis and received

the last dose at 0400

c. restart an infiltrated IV for a client whose antibiotic is scheduled for 0900

d. Replace a client's enteral nutrition feeding solution that has been hanging for 24

hours

(ANS- a. obtain a breakfast tray for a client who received a morning dose of

insulin.

A nurse is orienting a newly license nurse on the neurological unit. Which of the

following clients should the nurse assign to the newly licensed nurse?

a. A client who has multiple sclerosis and ataxia

b. a client who has a brain tumor and is admitted for chemotherapy

c. a client who has guillain-barre syndrome and a tracheostomy

d. a client who sustained a concussion and is being monitored for complications.

(ANS- a. a client who has multiple sclerosis and ataxia.

A nurse is providing teaching to a client about advance directives. Which of the

following client statements by the client indicates an understanding of the

teaching?