Nokea
A client is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?
- A. Flat rash on the client's ankle
- B. Non-blanching red area over the client's trochanter
- C. Ecchymosis on the client's left shoulder
- D. Petechiae on the client's right anterior thigh
Correct Answer: B
Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.
You may also like to solve these questions
A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
- A. Drink a cup of hot cocoa before bedtime
- B. Exercise 1 hour before going to bed
- C. Use progressive relaxation techniques at bedtime
- D. Reflect on the day's activities before going to bed
Correct Answer: C
Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.
A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?
- A. Collect at least 2 inches of formed stool.
- B. Wear sterile gloves while obtaining the specimen.
- C. Use a culturette for specimen collection.
- D. Record the date and time the stool was collected.
Correct Answer: A
Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?
- A. I will keep the cast covered the next day to prevent skin burning.
- B. I can apply an ice pack over the area to relieve itching inside the cast.
- C. The cast should be propped on at least 2 pillows when my child is lying down.
- D. I think I remember that standing cannot be done until after 72 hours.
Correct Answer: D
Rationale: The correct answer is D because there is no need to wait 72 hours before allowing the child to stand. The synthetic cast does not affect weight-bearing capacity, and standing can be done as tolerated. Choice A is incorrect because keeping the cast covered can lead to damage or accidents. Choice B is acceptable as applying an ice pack can help relieve itching. Choice C is also correct as elevating the cast on pillows can help reduce swelling and promote comfort during rest.
A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?
- A. Use tracheostomy covers when outdoors.
- B. Clean the tracheostomy with alcohol.
- C. Replace the tracheostomy tube every week.
- D. Cover the tracheostomy with a wet cloth when sleeping.
Correct Answer: A
Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.
The healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely to assess for complications?
- A. Serum sodium
- B. Serum calcium
- C. Blood urea nitrogen (BUN)
- D. Blood glucose
Correct Answer: D
Rationale: The correct answer is D: Blood glucose. Monitoring blood glucose levels is crucial for clients receiving total parenteral nutrition (TPN) due to the high glucose content in TPN solutions. TPN delivers essential nutrients, including glucose, directly into the bloodstream. Clients on TPN are at risk of developing hyperglycemia due to the concentrated glucose infusion. Therefore, close monitoring of blood glucose levels is necessary to detect and prevent hyperglycemia-related complications such as osmotic diuresis, hyperosmolarity, and electrolyte imbalances. While serum sodium, serum calcium, and blood urea nitrogen (BUN) levels are important parameters in various clinical scenarios, they are not specifically associated with TPN administration. These values are not the primary indicators to assess for complications in clients receiving TPN.