Nokea
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
- A. Cotton-tipped applicator
- B. Tongue depressor
- C. Adhesive tape
- D. Syringe
Correct Answer: D
Rationale: A syringe is used for irrigation to clean a stage 4 pressure injury with deep tissue involvement.
You may also like to solve these questions
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Tortuous veins
- B. Clammy skin
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a classic sign of DVT, requiring urgent reporting.
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
- A. Determine if the client has a support system.
- B. Schedule a mental health consult for the client.
- C. Provide the client with information about coping strategies.
- D. Encourage the client to attend a support group.
Correct Answer: A
Rationale: Assessing the support system first identifies resources to address ineffective coping.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Closing the client's eyes
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Removing dentures distorts facial appearance, requiring intervention.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. We will use an electric blanket to keep your partner warm.
- B. Encourage your partner to eat three large meals each day.
- C. Assume your partner can hear you, even if they do not respond.
- D. Opioids will be restricted if your partner develops respiratory distress.
Correct Answer: C
Rationale: Assuming hearing persists respects dignity and encourages communication in end-of-life care.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Check the client's range of motion every 6 hr.
- C. Secure the restraints with a square knot.
- D. Make sure two fingers fit under the restraints.
Correct Answer: D
Rationale: Ensuring two fingers fit prevents excessive tightness and circulation issues.