Nokea
The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?
- A. an elderly client who is up to the chair for meals with assistance
- B. a 24-year-old client with diabetes whose hemoglobin A1C is 6.4%
- C. a client who is legally blind and lives independently, except for driving
- D. a client with severe right-sided weakness from a stroke and residual peripheral neuropathy
- E. a client who had a right pneumothorax and has a chest tube and can reposition independently
Correct Answer: D
Rationale: Severe weakness and neuropathy (D) impair mobility and sensation, increasing pressure ulcer risk. Other clients have lower risk due to mobility or controlled conditions.
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A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply.
- A. provide the client with a call-light device
- B. keep the bed in the lowest position
- C. use a beveled floor mat at bedside
- D. implement a bed alarm
Correct Answer: A,B,D
Rationale: For a high fall risk client with Parkinson's, a call-light (A), low bed (B), and bed alarm (D) reduce fall risk. Beveled mats (C) are less standard and may pose tripping hazards.
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
- A. place the client in restraints or mitts
- B. tell the family that they need to stay with the client
- C. replace the IV and wrap it in gauze to hide it from view
- D. tell the client that if she pulls another IV out, she will have to have a PICC line placed
Correct Answer: C
Rationale: Wrapping the IV in gauze (C) is a least-restrictive method to prevent removal while maintaining dignity. Restraints (A) are a last resort, family presence (B) is impractical, and threats (D) are nontherapeutic.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A,B,E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity, requiring IV fluids (A), provider notification (B), and monitoring for symptoms like confusion and slurred speech (E). Diet (C) is unrelated, and further lithium (D) is contraindicated.
The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?
- A. Eschar is present on at least part of the wound.
- B. Full-thickness skin loss is present with undermining.
- C. Partial-thickness skin loss of the epidermis is present.
- D. The area is red and does not blanch with external pressure.
Correct Answer: B
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous fat and possible undermining, but not muscle or bone exposure.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Following the procedure, the nurse should be watching for which serious complications? Select all that apply.
- A. skin burns
- B. airway compromise
- C. cardiac dysrhythmias
- D. loss of bladder control
- E. neurological complications
Correct Answer: B,C,E
Rationale: ECT risks include airway compromise (B) from anesthesia, cardiac dysrhythmias (C) from stimulation, and neurological complications (E) like memory loss. Skin burns (A) and bladder loss (D) are not typical.