Nokea
A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with his amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct Answer: B
Rationale: An expected outcome is that the client falls asleep shortly after going to bed.
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While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
The client with an indwelling urinary catheter requires discharge teaching. Which interventions should the nurse include in the teaching plan? Select all that apply.
- A. Plan to change the urinary catheter once a week.
- B. Cleanse the perineal area daily with soap and water.
- C. Secure the catheter tubing to the thigh with tape.
- D. Avoid showering while the catheter is in place.
- E. Perform hand hygiene before and after catheter care.
Correct Answer: B,C,E
Rationale: B: Daily cleansing with soap and water prevents infection. C: Securing the catheter reduces trauma. E: Hand hygiene minimizes infection risk. A: Monthly changes are recommended unless blockage occurs. D: Showering is safe if the client's condition allows.
The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?
- A. Wearing the hose is unnecessary if ambulating 10 times daily for 5 minutes at a time.
- B. When at home, apply the stockings in the morning before you stand to get out of bed.
- C. The hose can cause pain to underlying skin; request pain medication to help alleviate this.
- D. Cross your legs only while wearing these stockings; otherwise keep the legs uncrossed.
Correct Answer: B
Rationale: B: Applying stockings before standing maximizes compression and prevents edema. A: Stockings complement ambulation. C: Pain suggests circulation issues, not requiring pain medication. D: Crossing legs impedes circulation.
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.