Nokea
A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Increased fluid intake
- B. Urinary incontinence
- C. Poor nutrition
- D. Immobility
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.
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A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Assess for signs of infection
- D. Administer prescribed antibiotics
Correct Answer: B
Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.
A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)
- A. Turn off the bed alarm
- B. Use physical restraints
- C. Maintain the bed in the lowest position
- D. Apply a vest restraint
Correct Answer: C
Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.
A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Turn off the oxygen when not in use
- C. Avoid open flames or smoking near oxygen
- D. Store the oxygen tubing near heat sources
Correct Answer: C
Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.
A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?
- A. Keep the client in one position
- B. Use a special mattress for the client
- C. Turn the client every 4 hours
- D. Provide extra pillows for positioning
Correct Answer: B
Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.
During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct Answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.