Nokea
A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct Answer: A
Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.
You may also like to solve these questions
Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse's plan be altered or modified?
- A. halfway through the shift
- B. at the end of the shift before the nurse reports off
- C. when needs change
- D. after the top-priority tasks have been completed
Correct Answer: C
Rationale: The nurse should modify the care plan whenever the client's needs change to ensure responsive and effective care, rather than at fixed times or only after completing tasks.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct Answer: A
Rationale: Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet.
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.