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A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Keep the head of the client’s bed elevated to 45
- B. Provide the client with a high-calorie diet
- C. Massage the client’s bony prominences
- D. Reposition the client every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Provide the client with a high-calorie diet. A high-calorie diet can help promote tissue healing and prevent pressure injuries by providing the necessary nutrients for skin integrity. Keeping the head of the bed elevated to 45 degrees (A) is important for preventing aspiration but not directly related to preventing pressure injuries. Massaging bony prominences (C) can actually increase the risk of pressure injuries by causing friction and shear forces. Repositioning the client every 4 hours (D) is essential but not directly related to the prevention of pressure injuries.
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A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the use of an incentive spirometer to a postoperative client
- B. Irrigate and perform a dressing change for a client who has a pressure injury wound
- C. Administer oral PRN pain medication to a client who has arthritis
- D. Obtain a daily weight on a client who has heart failure
Correct Answer: D
Rationale: The correct answer is D: Obtain a daily weight on a client who has heart failure. The rationale is as follows: Delegating the task of obtaining a daily weight to an assistive personnel (AP) is appropriate because it is a routine, non-invasive task that does not require specialized knowledge or skills. Daily weight monitoring is crucial for clients with heart failure to assess for fluid retention or loss, which is essential for managing the condition effectively. APs are trained to perform basic tasks like measuring weight and can report any significant changes to the nurse for further evaluation.
Summary of why the other choices are incorrect:
A: Teaching the use of an incentive spirometer requires specialized knowledge and skill that only a nurse should perform.
B: Irrigating and performing a dressing change for a pressure injury wound requires sterile technique and assessment skills that are beyond the scope of an AP.
C: Administering PRN pain medication involves assessing the client's condition, pain level, and potential side effects,
A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
A nurse is receiving report on a group of clients. Using the ABCDE priority framework which of the following clients should the nurse see first?
- A. A client who has early dementia and awoke confused to their location this morning
- B. A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
- C. A client who has pneumonia and has developed wheezing
- D. A client who is postoperative and has a urine output of 50 mL for the past 3 h
Correct Answer: C
Rationale: The correct answer is C because the client with pneumonia developing wheezing is experiencing a potential airway obstruction, impacting their breathing (airway). In the ABCDE priority framework, airway comes first to ensure adequate oxygenation. Choice A may indicate confusion but does not pose an immediate threat to life. Choice B has a fever, but unless there are other concerning symptoms, it does not require immediate attention. Choice D has decreased urine output, indicating a potential issue with circulation or kidneys, but it is not immediately life-threatening. Therefore, C takes precedence due to the potential airway compromise.
A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.