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A nurse is caring for a patient with limited mobility and is planning interventions to prevent pressure injuries. What action by the nurse demonstrates evidence-based practice in pressure injury prevention?
- A. Applying moisturizing lotion to the patient's skin daily
- B. Turning and repositioning the patient every 2 hours
- C. Placing the patient on an alternating pressure mattress
- D. Massaging the bony prominences to improve circulation
Correct Answer: C
Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.
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What tasks can be delegated to his nursing assistant during his tour of duty.
- A. Changing wound dressings.
- B. Administering analgesic drug.
- C. Performing a physical assessment.
- D. Taking vital sign
Correct Answer: A
Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.
Which of the following is usually involved in Multiple myeloma?
- A. Hematologic
- B. Neurologic
- C. Muscular
- D. Lymphoid
Correct Answer: A
Rationale: Multiple myeloma is a type of cancer that develops in plasma cells, which are a type of white blood cells involved in the body's immune response. As a result, multiple myeloma primarily affects the hematologic system, which includes the blood and blood-forming tissues. This cancer typically arises in the bone marrow and can lead to an overproduction of abnormal plasma cells, which can crowd out healthy blood cells. Symptoms of multiple myeloma can include anemia, bone pain, recurrent infections, fatigue, and kidney problems, all of which are related to the hematologic system.
Which of the following actions is appropriate for managing a conscious patient with a suspected stroke?
- A. Administering aspirin immediately.
- B. Placing the patient in a supine position.
- C. Encouraging the patient to eat and drink.
- D. Activating emergency medical services (EMS) for rapid transport to a stroke center.
Correct Answer: D
Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.
A patient is prescribed a tricyclic antidepressant for the management of depression. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypertension
- B. Hypotension
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: A
Rationale: Tricyclic antidepressants (TCAs) are known to have anticholinergic effects, which can lead to various cardiovascular side effects, including orthostatic hypotension, tachycardia, and potential hypertension. While hypotension is a possible adverse effect, hypertension is more commonly associated with TCAs. Therefore, it is essential for the nurse to monitor the patient for signs of hypertension, such as elevated blood pressure readings, to prevent any adverse outcomes and ensure the patient's safety while on this medication.
A patient receiving palliative care for end-stage dementia experiences agitation and restlessness. What intervention should the palliative nurse prioritize to address the patient's symptoms?
- A. Administer antipsychotic medications to manage agitation.
- B. Encourage the patient to engage in physical exercise to reduce restlessness.
- C. Create a calm and soothing environment to promote relaxation.
- D. Refer the patient to a psychiatrist for evaluation and medication management.
Correct Answer: C
Rationale: The most appropriate intervention for a patient with end-stage dementia experiencing agitation and restlessness is to create a calm and soothing environment to promote relaxation. Patients with dementia often respond positively to a familiar and tranquil setting, which can help reduce their symptoms of agitation and restlessness. This approach is preferred over administering antipsychotic medications or recommending physical exercise, as these may not be feasible or beneficial for patients in the advanced stages of dementia. Referring the patient to a psychiatrist may not address the immediate need for symptom management and can be considered if other interventions are ineffective. Creating a calm environment, such as dim lighting, soft music, and familiar objects, can help provide comfort and reduce distress for the patient.