Nokea
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
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The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
- A. Remove gown
- B. Remove gloves and perform hand hygiene
- C. Remove mask
- D. Remove eye protection
- E. Perform hand hygiene
Correct Answer: B,D,A,C,E
Rationale: B: Gloves are removed first due to high contamination risk, followed by hand hygiene. D: Eye protection is removed next. A: Gown is removed before leaving. C: Mask is removed at the doorway. E: Final hand hygiene ensures cleanliness.
Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct Answer: D
Rationale: Occult bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract.
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
The nurse is caring for the client with DM who has an open wound on the left heel. Which assessment findings should the nurse associate with a wound infection? Select all that apply.
- A. Oral temperature 100.6°F (38°C)
- B. Heel feels warm when touched
- C. Yellow and purulent drainage
- D. Reduced sensation in the left foot
- E. Elevated white blood cell count
Correct Answer: A,B,C,E
Rationale: A: Fever indicates possible infection. B: Warmth suggests inflammation or infection. C: Purulent drainage is a sign of infection. E: Elevated WBC count indicates an immune response to infection. D: Reduced sensation is related to neuropathy, not infection.
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: Participate with the compressions or breathing. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The client's advanced directives should have been filed on admission and his choices known prior to the initiation of CPR.