Nokea
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
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After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
- A. Wash with plain soap and water.
- B. sit in the sun for 10 min per day.
- C. Apply moist heat.
- D. Apply hydrating lotions.
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
- A. Hemolytic
- B. Allergic
- C. Febrile
- D. Bacterial
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?
- A. Alcohol use disorder
- B. Prolonged exposure to loud noises
- C. Exposure to environmental toxins
- D. Contact with excessive heat
Correct Answer: B
Rationale: Prolonged exposure to loud noises causes noise-induced hearing loss. Environmental toxins can also contribute, but noise exposure is the most direct and common risk factor.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse is caring for a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition?(Select All that Apply.)
- A. D-dimer blood test
- B. Complete blood count (CBC)
- C. CT scan
- D. Chest x-ray
- E. Lung ventilation and perfusion scan (VQ scan)
Correct Answer: A,C,E
Rationale: A D-dimer test measures clot breakdown products in the blood, with elevated levels suggesting the presence of an abnormal blood clot like in PE. A CT pulmonary angiography is the gold standard for diagnosing PE, providing detailed images of the lung's blood vessels. A VQ scan is another diagnostic tool for PE, especially for clients who cannot tolerate contrast dye, as it identifies ventilation-perfusion mismatches suggestive of PE. A CBC is not typically used to diagnose PE, and a chest x-ray is performed to rule out other causes but does not confirm PE.