Nokea
A client is hospitalized in a long-term care facility because of Alzheimer disease. The client is incontinent of urine and feces. The nurse has delegated incontinent care to unlicensed assistive personnel (UAP). How frequently should the nurse advise that the UAP check the client for dryness?
- A. Every 2 hours
- B. Every hour
- C. When the client appears restless.
- D. Before meals and at bedtime
Correct Answer: A
Rationale: Checking every 2 hours (A) ensures timely care to prevent skin breakdown in an incontinent client. Hourly checks (B) are excessive, and checking only when restless (C) or before meals (D) is insufficient.
You may also like to solve these questions
The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?
Correct Answer: 31
Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.
The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
- A. Body image disturbance
- B. Risk for infection
- C. Sensory perceptual alterations
- D. Activity intolerance
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.
A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?
- A. The client complains of feeling tired and listless.
- B. The client has waxy, pale skin.
- C. The client exhibits loss of coordination and position sense.
- D. The client has a rapid pulse rate and a detectable heart murmur.
Correct Answer: C
Rationale: Loss of coordination and position sense are neurological symptoms due to vitamin B12 deficiency in pernicious anemia.
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- A. Allow the client to keep the fruit
- B. Place the fruit next to the bed for easy access by the client
- C. Offer to wash the fruit for the client
- D. Ask the family members to take the fruit home
Correct Answer: D
Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.