CPNRE Nursing Care and Interventions 4 — Questions and Answers
Question 1: A client with a stage 3 pressure ulcer has yellow slough covering 70% of the wound bed. Which wound care intervention is most appropriate?
- Apply a dry sterile dressing and change daily
- Perform debridement to remove necrotic tissue (Correct answer)
- Pack the wound tightly with gauze soaked in normal saline
- Apply an occlusive transparent film dressing
Correct answer: Perform debridement to remove necrotic tissue
Debridement removes necrotic slough that impairs wound healing and promotes bacterial growth in stage 3 pressure ulcers.
Question 2: A nurse is caring for a client receiving continuous enteral tube feeding via nasogastric tube. Which action is the highest priority?
- Verify tube placement every 4 hours
- Keep the head of bed elevated at least 30 degrees (Correct answer)
- Flush the tube with 30 mL of water every 8 hours
- Weigh the client daily at the same time
Correct 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.
Question 3: 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?
- Administer the medication early given the high pain score
- Reassess the pain in one hour and administer if still elevated
- Notify the physician of the client's pain level and request a change in order
- Use non-pharmacological measures and reassess before next scheduled dose (Correct answer)
Correct 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.
Question 4: When performing tracheostomy care, the nurse notes the inner cannula is obstructed with thick secretions. What is the correct sequence of actions?
- Suction the tracheostomy, then remove and clean the inner cannula
- Remove the inner cannula, clean it in hydrogen peroxide, rinse with saline, and reinsert (Correct answer)
- Replace the entire tracheostomy tube and notify the physician
- Instill saline into the tracheostomy and suction to clear the obstruction
Correct 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.
Question 5: 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?
- Gentle tidaling in the water-seal chamber during breathing
- 25 mL of serosanguineous drainage in the first hour
- Subcutaneous emphysema around the insertion site (Correct answer)
- Absence of air bubbling in the suction control chamber
Correct 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.
Question 6: A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which nursing intervention is the priority?
- Encourage increased fluid intake to promote renal excretion
- Place the client on continuous cardiac monitoring (Correct answer)
- Administer a potassium-sparing diuretic as ordered
- Provide a high-potassium diet to correct electrolyte balance
Correct 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.
Question 7: A nurse is about to administer insulin glargine (Lantus) to a client. Which action is correct?
- Mix the insulin with regular insulin in the same syringe to reduce injections
- Administer the injection into the same site consistently for best absorption
- Do not mix with any other insulin and administer at the same time each day (Correct answer)
- Shake the vial vigorously before drawing up to ensure uniform suspension
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.
CPNRE Nursing Care and Interventions 4
A client with a stage 3 pressure ulcer has yellow slough covering 70% of the wound bed.
Which wound care intervention is most appropriate?