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A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position.
- B. Increase the client's intake of carbohydrates.
- C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
- D. Have the client use a trapeze bar when changing position
Correct Answer: B
Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet.
A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario.
C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown.
D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.
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Politics is a means for influencing events and the decisions of others. The nurse manager who consistently reminds the staff that 'there is no I in team' and periodically brings treats for the staff is using:
- A. Image enhancement
- B. Political skills
- C. Reward power
- D. Expert power
Correct Answer: B
Rationale: The correct answer is B: Political skills. The nurse manager is using political skills by emphasizing teamwork and building relationships through treats to influence the staff. This demonstrates an understanding of social dynamics and power structures within the team. Image enhancement (A) focuses on improving one's personal or professional reputation, not team dynamics. Reward power (C) involves using rewards or incentives to influence behavior, which is not the case here. Expert power (D) is based on knowledge and expertise, but the scenario does not indicate that the nurse manager is leveraging expertise to influence the team.
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
- A. give a bolus of 50% dextrose.
- B. insert a large-bore IV catheter.
- C. initiate oxygen via nasal cannula.
- D. administer glargine (Lantus) insulin.
Correct Answer: B
Rationale: The correct answer is B: insert a large-bore IV catheter. In HHS, patients are severely dehydrated due to high blood sugar levels. Inserting a large-bore IV catheter allows for rapid rehydration with isotonic fluids. This helps to correct the hyperosmolarity and electrolyte imbalances. Giving dextrose (choice A) would worsen hyperglycemia, initiating oxygen (choice C) is not directly related to managing HHS, and administering long-acting insulin like glargine (choice D) is not the initial priority in managing acute HHS.
A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
- A. Incident report completed.
- B. Client climbed over the side rails.
- C. Client was trying to get out of bed.
- D. Client found lying on floor.
Correct Answer: C
Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition.
Summary:
A: Incident report completed - Not relevant to documenting the client's actions during the fall.
B: Client climbed over the side rails - Assumes an action not reported by the roommate.
D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.
When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Position the client in a side-lying position.
- B. Perform the irrigation using a 20-mL syringe.
- C. Instill 15 mL of irrigation fluid into the catheter with each flush.
- D. Measure and record the amount of irrigant used.
Correct Answer: B
Rationale: The correct answer is B: Perform the irrigation using a 20-mL syringe. This is the correct action because using a 20-mL syringe allows for precise and controlled instillation of the irrigation fluid into the catheter. Using a smaller syringe helps prevent excessive pressure within the catheter, reducing the risk of trauma or damage to the client's urinary system.
A: Positioning the client in a side-lying position is not essential for open irrigation technique, as long as the client is comfortable and the procedure can be safely performed.
C: Instilling 15 mL of irrigation fluid with each flush may not be appropriate as the volume needed may vary based on the client's condition.
D: Although measuring and recording the amount of irrigant used is important for documentation purposes, it is not the immediate action to ensure the safe and effective irrigation of the catheter.
One way to determine staffing needs is to classify clients according to nursing care required. Another name for this is a(n) __________.
- A. self-scheduling
- B. supplementing staff system
- C. patient classification system (PCS)
- D. acuity system
Correct Answer: D
Rationale: The correct answer is D, acuity system. This system classifies clients based on the intensity of nursing care required. It helps determine staffing needs by matching the level of care needed with appropriate staffing levels. This method ensures that the right number and type of staff are available to meet patient needs efficiently. Choice A, self-scheduling, is about allowing staff to choose their own work schedules. Choice B, supplementing staff system, refers to adding additional staff when needed, not classifying clients. Choice C, patient classification system (PCS), is a general term and does not specifically focus on nursing care intensity like the acuity system does.