Nokea
Accurate documentation of assessment findings regarding pressure ulcers is very important because:
- A. The law requires the nurse to document lesions
- B. The hospital requires the nurse to document lesions
- C. The physician requires the nurse to document lesions
- D. The nursing assessment of ulcers is a standard of nursing practice
Correct Answer: D
Rationale: Documenting pressure ulcers is a nursing standard to promote continuity of care and prevent progression, not merely a legal or institutional requirement.
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A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency? A .Shear-reducing mattress B. Sequential compression devices C. Compression stockings D.Non-skid socks
- A. B and C
- B. A and D
- C. B and D
- D. A and C
Correct Answer: A
Rationale: For a client with venous insufficiency, sequential compression devices (SCDs) and compression stockings can be applied to improve venous return from the lower extremities.
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 nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.