Nokea
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
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The home health nurse is using the home Safety Assessment Scale to evaluate the dangers that may exist in the home of the client who is mildly cognitively impaired. Which finding on the scale should be most concerning to the nurse?
- A. Lives alone and has no spouse or living children
- B. Places cloth items on stove when burners are on
- C. Is unable to recognize when food is spoiled
- D. Has poor vision and doesn't wear glasses
Correct Answer: B
Rationale: Placing cloth items on a hot stove poses an immediate fire risk, which is the most concerning safety hazard for a cognitively impaired client.
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
Prior to checking a fingerstick blood glucose level, the nurse checks the identification band of the newly admitted client transferred from another facility. The nurse notes that the name and birth date are correct but that the band has the logo from another facility. Which is the best action by the nurse?
- A. Ask the UAP to obtain a new band while the nurse performs the planned procedure.
- B. Stop and replace the band with the current facility band that has the client identifiers.
- C. Ask the client to state his or her name and birth date and to verify them against the band.
- D. Leave the band in place; a name band from one facility can be used in another facility.
Correct Answer: B
Rationale: Replacing the band ensures the medical record number matches the current facility, preventing errors during procedures.
The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?
- A. urinalysis
- B. creatinine and blood urea nitrogen
- C. chemistry of electrolytes
- D. creatinine clearance
Correct Answer: D
Rationale: Due to decreases in lean body mass, blood creatinine is not as good an indicator of the elderly client's renal function as creatinine clearance. Creatinine clearance is a widely used test for glomerular filtration rate.
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.