Nokea
A client is immobile and requires mechanical ventilation with a tracheostomy.
She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse
observes bone and tendon at the base of the wound. How would the nurse
document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct Answer: D
Rationale:
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A client has a new diagnosis of human immunodeficiency virus HIV. The client
is distraught and does not know what to do. What intervention by the nurse is
the best?
- A. Offer to tell the family for the client
- B. Call the hospital clergy to speak with the client
- C. Assess the client's support system
- D. Explain the legal requirements to tell sex partners
Correct Answer: C
Rationale:
A nurse is teaching a newly hired group of unlicensed assistive personnel
about infection-control measures on the unit. What is the most effective way to
prevent the spread of pathogens during client care?
- A. Properly dispose of contaminated equipment
- B. Perform hand hygiene
- C. Discard used syringes into appropriate containers
- D. Change soiled linens
Correct Answer: B
Rationale:
A client arrives speaking only Spanish. What is the priority nursing
intervention?
- A. Give the client a tour of the unit
- B. Verify the reason for admission
- C. Request a medical interpreter
- D. Call the chaplain for support
Correct Answer: C
Rationale:
The nurse is most concerned about which of these findings in a client with
systemic lupus erythematous?
- A. The client reports chronic fatigue
- B. The client has a butterfly rash
- C. Blood pressure of 126/85 mm Hg
- D. Urine output of 20 mL/hour
Correct Answer: D
Rationale:
The nurse is caring for a client who develops compartment syndrome from a
severely fractured arm. The client asks how this can happen. What is the best
response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct Answer: C
Rationale: