Nokea
Assessment of a client with a cast should include:
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct Answer: A
Rationale: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.
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The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
- A. Massage vigorously over bony prominences daily
- B. Wear sterile gloves when inspecting the client's skin
- C. Apply a moisturizing lotion to bony prominences
- D. Instruct the client to change position every 2 hours
- E. Apply an overhead trapeze to the client's bed
- F. Apply a barrier cream if the client is incontinent of stool
Correct Answer: C,D,E,F
Rationale: C: Moisturizers prevent dry skin. D: Repositioning improves circulation. E: Trapezes reduce friction during movement. F: Barrier creams protect against incontinence. A: Vigorous massage causes tissue trauma. B: Sterile gloves are unnecessary unless breakdown exists.
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Compliance or performance at the minimally acceptable level is not considered quality care.
The hospitalized client is able to stand to use an electronic digital scale for obtaining the client's prescribed daily weight. Which nursing interventions best ensure that the client's daily weight is accurate? Select all that apply.
- A. Ask the client to wear supportive shoes before stepping on the scale
- B. Ensure that the scale is calibrated and “zeroed†before a weight is obtained
- C. Weigh the client by moving the sliding indicator until the scale balances
- D. Weigh the client at different times of the day and then average the weights
- E. Take the weight as soon as the client wakens in the morning and after voiding
Correct Answer: B,E
Rationale: B: Calibration ensures accuracy. E: Weighing post-voiding at the same time daily standardizes results. A: Shoes add weight. C: Sliding indicators are for balance scales. D: Averaging weights reduces accuracy.
Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
For a client requiring total oral care, it is important for the nurse to:
- A. assemble all equipment, assist the client to semi-Fowler's position, and place a towel on his chest.
- B. place client in Fowler's position, prepare the equipment, and tell the client what to do.
- C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- D. use gloves and clean the client's mouth, including the tongue.
Correct Answer: C
Rationale: Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn.