Nokea
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
- A. Unbroken skin with un-blancheable erythema
- B. Full-thickness tissue loss extending to underlying support structures
- C. A shallow, ruptured or intact skin blister without slough
- D. A deep crater without visible bone, tendon, or muscle
Correct Answer: D
Rationale: Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but without exposed bone or muscle.
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A nurse is caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Turn and position each client every 2 hr.
- B. Identify the clients at greatest risk for development of pressure ulcers.
- C. Use a barrier cream when performing perineal care.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: B
Rationale: The correct answer is B: Identify the clients at greatest risk for development of pressure ulcers. This is the priority because it allows for targeted interventions to be implemented for those most vulnerable, maximizing resources and preventing potential harm. Turning and positioning clients, using barrier creams, and ensuring adequate nutrition are all important aspects of pressure ulcer prevention, but they should be tailored based on individual risk assessment. Supervising nutritional intake is crucial, but not the immediate priority in preventing pressure ulcers. Identifying high-risk clients allows for proactive measures to be taken, making it the most critical step in meeting the National Safety Goal.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
- A. I am thinking of getting a second opinion.
- B. I am hoping this will help relieve my discomfort.
- C. This is making me stronger every day.
- D. This is not working, and I plan to stop treatment.
Correct Answer: B
Rationale: Palliative care focuses on symptom relief, and the statement reflects an understanding of this goal.
A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.