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After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education?
- A. I can help him shift his position every hour when he sits in the chair.
- B. If his tailbone is red and tender in the morning, I will massage it with baby oil.
- C. Applying lotion to his arms and legs every evening will decrease dryness.
- D. Drinking a nutritional supplement between meals will help maintain his weight.
Correct Answer: B
Rationale: Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.
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A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
- A. Cool, moist compresses
- B. Topical corticosteroids
- C. Heating pad
- D. Tepid bath with cornstarch
- E. Back rub with baby oil
Correct Answer: A,D
Rationale: Cool, moist compresses and tepid baths with cornstarch reduce inflammation and help debride crusts in eczematous dermatitis. Topical corticosteroids are pharmacologic, and heating pads or baby oil may increase inflammation and discomfort.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
- A. A 44-year-old prescribed IV antibiotics for pneumonia
- B. A 26-year-old who is bedridden with a fractured leg
- C. A 65-year-old with hemiplegia and incontinence
- D. A 78-year-old requiring assistance to ambulate with a walker
Correct Answer: C
Rationale: Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.)
- A. Prepare a room for reverse isolation.
- B. Assess staff for a history of or vaccination for chickenpox.
- C. Check the admission orders for analgesia.
- D. Choose a roommate who also is immune suppressed.
- E. Ensure that gloves are available in the room.
Correct Answer: B,C,E
Rationale: Herpes zoster (shingles) is caused by reactivation of the varicella zoster virus, and staff without immunity to chickenpox are at risk. Analgesia is necessary due to the painful nature of shingles. Gloves and hand hygiene prevent spread, but reverse isolation is not required. An immune-suppressed roommate should be avoided to prevent infection transmission.
After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?
- A. I'll apply cortisone cream to reduce the inflammation.
- B. I'll apply a clean dressing after squeezing out the pus.
- C. I'll keep my arm down at my side to prevent spread.
- D. I'll cleanse the area prior to applying antibiotic cream.
Correct Answer: D
Rationale: Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infection process. Squeezing the lesion may introduce infection to deeper tissues and cause folliculitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.
A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Wash your hands before touching the client.
- B. Wear gloves when bathing the client.
- C. Assess skin for breakdown during the bath.
- D. Apply lotion to lesions while the skin is wet.
- E. Use a damp cloth to scrub the lesions.
Correct Answer: A,B
Rationale: All health care providers should follow Standard Precautions when caring for clients with open skin lesions, including hand hygiene and wearing gloves. UAPs are not qualified to assess skin or apply lotion to lesions, and scrubbing lesions is inappropriate as it may cause further damage.