Nursing Care and Interventions Flashcards

A client with a stage 3 pressure ulcer has yellow slough covering 70% of the wound bed. Which wound care intervention is most appropriate?

Answer: Perform debridement to remove necrotic tissue

Debridement removes necrotic slough that impairs wound healing and promotes bacterial growth in stage 3 pressure ulcers.

A nurse is caring for a client receiving continuous enteral tube feeding via nasogastric tube. Which action is the highest priority?

Answer: Keep the head of bed elevated at least 30 degrees

Maintaining head of bed elevation at ≥30 degrees is the highest priority to prevent aspiration pneumonia during enteral feeding.

A client post-total knee replacement reports pain of 7/10 and asks for their analgesic. The nurse notes the last dose was given 3 hours ago and the order states every 4 hours PRN. What is the best action?

Answer: Use non-pharmacological measures and reassess before next scheduled dose

The nurse should respect the prescribed interval, use non-pharmacological comfort measures, and reassess before the next due time, notifying the physician if pain remains uncontrolled.

When performing tracheostomy care, the nurse notes the inner cannula is obstructed with thick secretions. What is the correct sequence of actions?

Answer: Remove the inner cannula, clean it in hydrogen peroxide, rinse with saline, and reinsert

The inner cannula should be removed, cleaned with hydrogen peroxide to loosen secretions, rinsed with normal saline, and reinserted to restore airway patency.

A nurse is caring for a client with a newly inserted chest tube connected to a water-seal drainage system. Which finding requires immediate intervention?

Answer: Subcutaneous emphysema around the insertion site

Subcutaneous emphysema around the insertion site indicates air leaking into subcutaneous tissue, which requires immediate assessment and intervention.

A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which nursing intervention is the priority?

Answer: Place the client on continuous cardiac monitoring

Hyperkalemia causes life-threatening cardiac dysrhythmias, so continuous cardiac monitoring is the immediate priority to detect changes.

A nurse is about to administer insulin glargine (Lantus) to a client. Which action is correct?

Answer: Do not mix with any other insulin and administer at the same time each day

Insulin glargine must never be mixed with other insulins and should be administered at the same time each day to maintain consistent basal coverage.