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A nurse is reviewing the health history of an older adult who has a hip fracture. The nurse should identify what is a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for skin breakdown and pressure injuries.
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A nurse is preparing a client for transfer to another unit. Which finding does the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct Answer: D
Rationale: All findings are important for ensuring continuity of care in the transfer report.
A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct Answer: C
Rationale: Immunizations provide acquired immunity, as they introduce antigens into the body, prompting the production of antibodies.
A charge nurse is making assignments for the upcoming shift. What assignment should the charge nurse give to an LPN?
- A. A client who requires complex medication management
- B. A client who has dehydration and inflammatory bowel disease (IBD)
- C. A client needing assessment of a new diagnosis
- D. A client requiring a nursing care plan update
Correct Answer: B
Rationale: A client with dehydration and IBD does not require complex medication administration, making this an appropriate assignment for an LPN.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.