Nokea
A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following interventions should the healthcare provider include?
- A. Massage the ulcer
- B. Apply a heating pad
- C. Reposition the client every 2 hours
- D. Use alcohol-based cleansers
Correct Answer: C
Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.
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The nurse listened to Mr. Gary to build trust. This is an example of?
- A. Therapeutic communication
- B. Reflective practice
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
- A. The mottled appearance of the trunk
- B. The presence of conjunctival hemorrhages
- C. Cyanosis of the hands and feet
- D. Respiratory rate of 20-28 per minute
Correct Answer: C
Rationale: A 5-minute Apgar score of 9 typically reflects one point deduction, often for color, with cyanosis of the hands and feet (acrocyanosis) being common in newborns, especially post-C-section, due to initial circulation adjustments. Mottling or hemorrhages don't directly score points off, and a respiratory rate of 20-28 is low (normal is 30-60), potentially docking more points. Nurses recognize acrocyanosis as benign, resolving naturally, and use this score to reassure parents while monitoring transition, ensuring no further intervention is needed.
When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?
- A. Tremors
- B. Urine retention
- C. Kussmaul respirations
- D. Bradypnea
Correct Answer: C
Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood.
A healthcare professional is assessing a client who has chronic pain. Which of the following findings should the healthcare professional expect?
- A. Hypotension
- B. Tachycardia
- C. Hyperthermia
- D. Depression
Correct Answer: D
Rationale: Chronic pain is associated with various psychological effects, including depression. Clients experiencing chronic pain may develop feelings of hopelessness, helplessness, and despair, which are characteristic of depression. It is essential for healthcare professionals to recognize and address these psychological impacts when caring for clients with chronic pain.
A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will decrease my intake of potassium.
- B. I will increase my intake of vitamin K.
- C. I will decrease my intake of sodium.
- D. I will increase my intake of magnesium.
Correct Answer: C
Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided.