Nokea
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea.
Based on the nursing assessment, an appropriate priority nursing diagnosis is
- A. risk for constipation related to immobilization.
- B. risk for impaired skin integrity related to immobilization and secretions.
- C. risk for wound infection related to involuntary bowel secretions.
- D. risk for fluid volume excess related to secretions.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) constipation is not a problem because the client has diarrhea (2) correct-skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) there would be risk of fluid volume deficit due to diarrhea and secretions
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The LPN/LVN is making assignments in a long-term care facility. Staff on duty include another LPN and a new certified nursing assistant. Which client can most safely be assigned to the nursing assistant?
- A. Ms. A., 92 years old, has dementia and advancing congestive heart failure (CHF).
- B. Ms. B., 83 years old, has Alzheimer's and Parkinson's and is ambulatory with assistance.
- C. Mr. C., 76 years old, has just been transferred from an acute care facility where he had a total hip replacement four days ago.
- D. Mr. D., 29 years old, had a closed head injury and is in a semi-vegetative state with a tracheostomy and a gastrostomy.
Correct Answer: B
Rationale: Ms. B's ambulatory status with assistance aligns with CNA tasks like hygiene and transfers, safest for a new CNA compared to complex needs.
The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
A withdrawn, depressed client sits in the day room but refuses to participate in scheduled group activities. When implementing a plan of care the nurse should:
- A. Plan activity that will allow the client to interact with a staff member.
- B. Tell the client that participation in group activities is expected.
- C. Allow the client to select an activity that he can enjoy doing alone.
- D. Ask the client to prepare a list of activities or hobbies he enjoys.
Correct Answer: A
Rationale: One-on-one interaction with a staff member encourages engagement without overwhelming a depressed client. Mandating participation may increase withdrawal. Solitary activities (C, D) do not address social isolation.
The nurse is caring for a client who has a cervical radioactive implant. Which action is not appropriate for the nurse when caring for this client?
- A. Post a radioactive symbol on the client's chart and on the door to the room.
- B. Put on gloves to remove any radioactive implant that may have come out.
- C. Wash hands with soap and water after caring for the client.
- D. Limit the amount of time with the client.
Correct Answer: B
Rationale: Removing a radioactive implant requires specialized handling, not just gloves, to avoid exposure, making this action inappropriate.