1. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is four centimeters by seven centimeters, the wound base is red and moist with no exudate and the surrounding skin is intact. Which covering should a nurse select for this wound?

    B. Occlusive moist dressing

    rationale: This wound has granulation tissue present and must be protected. The granulation tissue is evident by wound base being red and moist with no exudate. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.
  2. Which of the following statements indicate a client understands how to safely take alendronate (Fosamax)? ( Select all that apply )

    a. "I will always eat breakfast before taking it."
    b. "I will notify the health care provider if I have any difficulty swallowing."
    c. "I will quietly rest for 30 minutes after taking it."
    d. "I will swallow it with 8 ounces of water."
    e. "I will take the pill immediately preceding weight bearing exercise."
    B, C, and D

    Rationale: This medication can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication.
  3. A three year-old child diagnosed with celiac disease attends a day care center. Which food would be an appropriate snack?

    C. Potato chips

    Rationale: Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible by persons diagnosed with celiac disease.
  4. If the nurse notes cloudy drainage two days post insertion of a Tenckhoff catheter for peritoneal dialysis, what other data does the nurse need to collect before reporting this finding?

    A. Temperature

    Rationale: This finding indicates potential infection, so it is essential to evaluate temperature before notifying the health care provider
  5. Newer treatments for cancer include the use of biological response modifier cancer therapy agents. Of the findings commonly associated with type type of cancer treatment, which of the following assessments will the nurse anticipate and document?
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