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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
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A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen?
- A. Avoid eating red meat.
- B. Increase fiber intake.
- C. Take an iron supplement.
- D. Drink grapefruit juice.
Correct Answer: A
Rationale: The correct answer is A: Avoid eating red meat. Red meat can cause false positives in fecal occult blood tests due to the presence of heme iron which can be mistaken for blood. Instructing the client to avoid red meat for 3 days prior to collecting the specimen helps to ensure the accuracy of the test results.
Summary:
B: Increasing fiber intake does not directly impact the accuracy of the fecal occult blood test.
C: Taking an iron supplement can interfere with the test results by increasing the amount of iron in the stool, leading to false positives.
D: Drinking grapefruit juice is not relevant to the accuracy of the fecal occult blood test.
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
- A. Skin changes
- B. Hypertension
- C. Diarrhea
- D. Increased white blood cell count
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (B), diarrhea (C), and increased white blood cell count (D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct answer is C (Aspirin) and E (Naproxen). Aspirin and Naproxen are both NSAIDs that can increase the risk of bleeding when taken with warfarin, which is an anticoagulant. The combination can lead to excessive anticoagulation and potential bleeding complications. Ferrous sulfate (A) does not interact significantly with warfarin. Echinacea (B) is an herbal supplement that may have interactions with some medications, but not warfarin specifically. Dextromethorphan (D) is a cough suppressant and does not have a significant interaction with warfarin. In summary, Aspirin and Naproxen should be avoided with warfarin due to the increased risk of bleeding, while the other options do not have significant interactions with warfarin.
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.