Nokea
A nurse is collecting data from a client's skin. Which of the following actions should the nurse take to assess skin turgor?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size red or purple spots.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This method assesses skin turgor by evaluating how quickly the skin returns to its normal position after being pinched. Adequate skin turgor indicates good hydration status, as hydrated skin will snap back promptly. If the skin remains elevated or "tents," it may indicate dehydration. Choice A involves palpation, which assesses skin temperature and texture but not turgor. Choice B involves assessing edema, not skin turgor. Choice C describes petechiae, which are indicative of bleeding disorders. Overall, choice D is the most appropriate for assessing skin turgor accurately.
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A nurse is caring for a client who has pneumonia. The nurse should place the client on his right side in Trendelenburg position to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: The Trendelenburg position promotes drainage of secretions from specific lung segments, improving oxygenation.
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.
A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.
A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage of the apical lung segments. Which of the following statements by the client should the nurse identify as understanding of the teaching?
- A. I will sit up on the side of the bed with my legs dangling.
- B. I will turn on my left side with my legs elevated higher than my chest.
- C. I will position myself on my back with my head lower than my feet.
- D. I will lie on my abdomen with pillows under my stomach and chest.
Correct Answer: D
Rationale: Prone positioning with pillows under the chest promotes postural drainage of apical lung segments. Other positions are ineffective.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.