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A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's impairs mobility and cognition, increasing pressure ulcer risk from prolonged immobility. Turning the client every 2 hours redistributes pressure, maintains skin integrity, and aligns with evidence-based prevention (e.g., Braden Scale interventions). A mirror for reality orientation is ineffective late-stage patients lack recognition, and it may cause distress. Written instructions are useless due to severe cognitive decline; simplified, hands-on guidance is better for tasks like oral hygiene. Open-ended questions frustrate clients unable to process or respond, whereas yes/no prompts suit their capacity. Regular repositioning addresses a physical priority, prevents costly complications like infections or surgery, and supports dignity in care, making it the essential action for this vulnerable population.
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A nurse is caring for a client who is 3 days postoperative following an ileostomy placement. Which of the following findings should the nurse report to the provider?
- A. Stoma retracts into the abdominal wall.
- B. Stoma is a cherry red color.
- C. Stool contains scant red blood.
- D. Stool is a dark green color.
- E. Stoma is pale and dry.
- F. Stool is watery and excessive.
- G. Stoma is swollen and painful.
Correct Answer: A
Rationale: A retracted stoma is a complication requiring intervention; cherry red is normal, scant blood and dark green stool are expected early post-op.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Clamp the tube for 30 min every 8 hr.
- C. Pin the tubing to the client's bed sheets.
- D. Monitor for at least 150 mL of drainage every hour.
Correct Answer: A
Rationale: Replacing the unit when full maintains system function. Clamping risks tension pneumothorax, pinning can dislodge tubing, and 150 mL/hr is excessive and not a standard expectation.
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Empty the urine into a sterile container labeled with the client identifiers.
- B. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- E. Clamp the catheter tubing distal to the sampling port for 15 min.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (D), aspirate (C), transfer (A), document (B) ensures sterility and proper procedure.
Exhibit 1 Exhibit 2 Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg
Temperature 38.6° C (101.5° F)
Respiratory rate 24/min
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse to report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
Correct Answer: C
Rationale: Pneumonia, an acute respiratory infection, requires monitoring for signs of worsening condition or treatment response. The exhibit shows heart rate 112/min, blood pressure 122/60 mm Hg, temperature 38.6°C (101.5°F), and respiratory rate 24/min. Option C, temperature, is the priority 38.6°C indicates fever, a key sign of active infection or potential sepsis, especially with tachycardia (112/min) and tachypnea (24/min). This triad suggests systemic inflammatory response, needing urgent provider attention to adjust antibiotics or assess deterioration. Option A, sputum results, guides therapy but isn't immediately actionable without context. Option B, creatinine, monitors kidney function but isn't the acute priority here. Option D, WBC count, reflects infection severity but fever drives immediate concern. Elevated temperature, per triage protocols, signals potential escalation, making it the most critical to report for timely intervention.