Nokea
A nurse evaluates the following data in a clients chart: 66-year-old male with a health history of cerebral vascular accident and left-side paralysis, white blood cell count: 8000/mm^3, prealbumin: 15.2 mg/dL, albumin: 4.2 g/dL, lymphocyte count: 2000/mm^3, sacral ulcer 4 cm x 2 cm x 1.5 cm. Based on this information, which action should the nurse take?
- A. Consult a dietitian to increase nutritional intake.
- B. Apply a transparent film dressing to the ulcer.
- C. Reposition the client every 4 hours.
- D. Administer antibiotics for wound infection.
Correct Answer: A
Rationale: The prealbumin level of 15.2 mg/dL is low (normal range is typically 15"?36 mg/dL), indicating potential malnutrition, which can impair wound healing. Consulting a dietitian to optimize nutritional intake is the priority to support tissue repair. The white blood cell count is normal, so antibiotics are not indicated. Transparent film dressings are not suitable for deep ulcers, and repositioning should occur more frequently than every 4 hours.
You may also like to solve these questions
A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
- A. Cool, moist compresses
- B. Topical corticosteroids
- C. Heating pad
- D. Tepid bath with cornstarch
- E. Back rub with baby oil
Correct Answer: A,D
Rationale: Cool, moist compresses and tepid baths with cornstarch reduce inflammation and help debride crusts in eczematous dermatitis. Topical corticosteroids are pharmacologic, and heating pads or baby oil may increase inflammation and discomfort.
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?
- A. Viral infection: Clindamycin (Cleocin)
- B. Bacterial infection: Acyclovir (Zovirax)
- C. Yeast infection: Linezolid (Zyvox)
- D. Fungal infection: Ketoconazole (Nizoral)
Correct Answer: D
Rationale: Ketoconazole is an antifungal medication appropriate for fungal infections. Clindamycin and Linezolid are antibiotics used for bacterial infections, and Acyclovir is an antiviral drug used for viral infections.
A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)
- A. Use a lift sheet when moving the client in bed.
- B. Avoid tape when applying dressings.
- C. Avoid whirlpool therapy.
- D. Use loose dressing on all wounds.
- E. Implement pressure-relieving devices.
Correct Answer: A,B,E
Rationale: Using a lift sheet prevents shearing forces, avoiding tape protects fragile skin, and pressure-relieving devices reduce pressure ulcer risk. Whirlpool therapy is not contraindicated, and dressings should be applied as prescribed, not necessarily loose.
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.