Nokea
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
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A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.
A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?
- A. Phosphorus
- B. Iron
- C. Magnesium
- D. Potassium
Correct Answer: B
Rationale: Iron in hemoglobin binds oxygen for transport in the blood.
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?
- A. Vitamin C
- B. Iron
- C. Potassium
- D. Niacin
Correct Answer: A
Rationale: Vitamin C is essential for collagen synthesis and wound healing. It helps improve the strength of the wound and promotes tissue repair, making it crucial for clients healing by secondary intention.