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A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Use of a special mattress
- D. Urinary incontinence
Correct Answer: C
Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.
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A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?
- A. Increased breath sounds
- B. Flushed skin
- C. Nasal flaring
- D. Decreased respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.
A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?
- A. Bladder distention
- B. Bladder spasms
- C. Hematuria
- D. Increased urine output
Correct Answer: A
Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.
A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?
- A. I can change my living will whenever I want.
- B. I do not need a living will if I have a durable power of attorney.
- C. My family will make decisions for me if I am unable to.
- D. I need a living will only if I am seriously ill.
Correct Answer: A
Rationale: The correct answer is A because the client understanding that they can change their living will whenever they want shows comprehension of advance directives. Choices B, C, and D are incorrect: B is inaccurate as both documents serve different purposes; C may not always be the case based on the client's wishes and legal documents; D is incorrect because a living will is not only for serious illness but also for end-of-life care decisions.
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.
A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?
- A. Crush medications and mix them with honey
- B. Provide medications through a straw
- C. Place the medications in small amounts of pudding
- D. Offer the medications with a full glass of water
Correct Answer: C
Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.