MDC 1 Final Exam Study Guide Questions with 100% Verified Correct Answers A client arrives speaking only Spanish. What is the priority nursing intervention? - Correct Answer Request a medical interpreter.A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation? - Correct Answer Once the tissue has necrosed from high-pressure. It does not regenerate.A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is the best? - Correct Answer Assess the client's support system.A client has AIDS. Which of these assessment findings indicate possible infection? (Select all) - Correct Answer -Temperature of 101.3 degrees Fahrenheit.-Purulent drainage A client has an abdominal incision. The surgical wound has closed with 10 sutures. This surgical wound is healing by what process? - Correct Answer Primary intention A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding? - Correct Answer Purulent A client has been suffering from arthritis for many years and is experiencing an exacerbation. The client states he has a lot of stress from his position as an administrative assistant, and his job is not getting better. What is the most appropriate response from the nurse? - Correct Answer "You are stating that this job is not getting better. Tell be more about that" A client has cellulitis on his left arm. What statement by the client indicates understanding of system management? - Correct Answer "I can use a warm, moist towel on my arm." A client has suffered from a femur fracture. What is the nurse's priority assessment? - Correct Answer Pedal pulse A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client? - Correct Answer Use proper hand hygiene and strict infection control 1 / 2
A client is admitted for treatment of a wound. What is true about wound healing and nutrition? - Correct Answer Wound healing is negatively impacted by poor nutrition.A client is bedridden and appears to be frail and malnourished. Which nursing intervention will decrease the risk of pressure injury? (Select all) - Correct Answer -Applying moisturizer to dry areas of the skin.-Cleansing the skin routinely after soiling occurs.-Using a Hoyer lift for all transfers A client is diagnosed with narcolepsy. What is the nurse's priority intervention? - Correct Answer Inform the client that driving would be dangerous.A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur? - Correct Answer Raynaud's phenomenon A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next? - Correct Answer Raise the arm above the level of the heart.A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5cm by 3cm. The nurse observes bone and tendon at the base of the wound. How would the nurse document this wound? - Correct Answer Stage IV pressure injury A client is in skeletal traction. With the nurse's assessment, it is noted that the pin appears red, and swollen and there is purulent drainage. What action does the nurse take first? - Correct Answer Collect a culture of the purulent fluid.A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught.What is the priority nursing action? - Correct Answer Maintain the client's blood pressure A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action? - Correct Answer Assess the wound for signs of dehiscence.
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