Nokea
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
- A. Reassess the patient and situation.
- B. Revise the turning schedule to increase the frequency.
- C. Delegate turning to the nursing assistive personnel.
- D. Apply medication to the area of skin that is broken down.
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan.
B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer.
C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer.
D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
You may also like to solve these questions
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery.
Incorrect choices:
B: Hiccups - Hiccups are not a common side effect of Ketamine administration.
C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions.
D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids.
Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.
Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
- A. Apply zinc oxide to the surrounding skin
- B. Use a binder to hold the dressing in place
- C. Support the arm and the shoulder with pillows
- D. Instruct the client not to shave the axillary hair on the side with abscess
Correct Answer: A
Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration.
Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Squeeze the nipple to check for drainage
- C. Check the area after the next menstrual period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.
Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.
At a public health fair, the nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:
- A. Fever.
- B. Nipple discharge and a breast nodule.
- C. Breast changes during menstruation.
- D. Fever and erythema of the breast.
Correct Answer: B
Rationale: The correct answer is B because nipple discharge and a breast nodule are classic signs of breast cancer. Nipple discharge can be bloody or clear, and a breast nodule is a lump that feels different from the surrounding tissue. Fever (choice A) is not a common sign of breast cancer. Breast changes during menstruation (choice C) are normal hormonal fluctuations. Fever and erythema of the breast (choice D) are more indicative of an infection rather than breast cancer. Therefore, choice B is the most relevant sign of breast cancer among the options provided.