Nokea
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
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A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?
- A. Postoperative cognitive dysfunction
- B. Dementia
- C. Alzheimer's disease
- D. Postoperative delirium
Correct Answer: D
Rationale: Postoperative delirium causes acute, temporary confusion post-surgery, common in older adults.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?
- A. Manifestations of hypoglycemia
- B. Height of the IV pole
- C. IV insertion site
- D. The client's oral intake
Correct Answer: C
Rationale: Monitoring the IV insertion site is critical for TPN due to the high risk of infection and complications with central lines.