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A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?
- A. Increase in oil production
- B. Decrease in elasticity
- C. Increase in pigmentation
- D. Decrease in moisture levels
Correct Answer: B
Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.
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A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?
- A. Age and gender
- B. High-fat diet, smoking, alcohol consumption
- C. Ethnicity and race
- D. Exposure to radiation
Correct Answer: B
Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.
A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?
- A. Reposition the client every 4 hours
- B. Apply lotion to the skin every 2 hours
- C. Use a special mattress to reduce pressure on the skin
- D. Increase fluid intake to promote skin hydration
Correct Answer: C
Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.
While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.
A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?
- A. Administer the medication with a straw
- B. Flush the NG tube with 30 mL of water before administration
- C. Crush all medications together
- D. Mix the medication with pudding
Correct Answer: B
Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.
A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Orange slices
- C. Mashed potatoes
- D. Baked chicken
Correct Answer: B
Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.