Nokea
A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?
- A. Heat from pressure
- B. Collapse of blood vessels
- C. Friction from pressure
- D. Collapse of skin tissue
Correct Answer: B
Rationale: A pressure injury occurs when there is sufficient pressure to collapse the blood vessels.
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Proper hair care is important for the patient's self-image. What is the proper water temperature when shampooing a patient's hair?
- A. 101°F (38.3°C)
- B. 105°F (40.5°C)
- C. 110°F (43.3°C)
- D. 120°F (48.8°C)
Correct Answer: C
Rationale: Water at 110°F (43.3°C) should be used to shampoo a patient's hair.
The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?
- A. Back-lying
- B. Full lateral
- C. 30-degree lateral
- D. Full prone
Correct Answer: C
Rationale: It is preferable to use the 30-degree lateral incline position.
The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?
- A. Nursing care
- B. Independence
- C. Repetition
- D. Performance
Correct Answer: B
Rationale: The nurse should encourage the patient's independence as much as possible.
The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?
- A. Washing the leg with long firm strokes and drying with a towel
- B. Omitting washing the leg at all
- C. Gently washing the leg and patting dry with a towel
- D. Applying lotion in long smooth strokes
Correct Answer: C
Rationale: The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging.
What should the water temperature be when preparing a tepid bath for a patient?
- A. 98.6°F (37°C)
- B. 100.2°F (37.8°C)
- C. 104.8°F (40.4°C)
- D. 110.4°F (43.5°C)
Correct Answer: A
Rationale: The tepid bath is taken in water that is 98.6°F (37°C).