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Nurses votes
Skin assessment reveals a stage 2 pressure injury on the right trochanter. Measures 0.79" x 1.57" x 0.39 (2 cm X 4 cm X 1 cm). Minimal drainage noted. Painful to touch. The Braden Scale was utilized during the skin assessment. The score is two for sensory, three for moisture, two for activity, two for mobility, two for nutrition and one for friction and shear.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
A. Begin enteral feedings
B. Insert Indwelling urinary catheter
C. Ambulate every four
D. Apply pressure reduction mattress to bed
E. Request service of wound care nurse
- B. Potential Conditions
Choices
A. Immobility
B. Dehydration
C. Malnutrition
D. Poor healing of stage 2 pressure injury
- C. Parameters to monitor
Choices
A. Sterile dressing changes
B. Adherence to repositioning schedule hours
C. Temperature
D. Laboratory studies for malnutrition status
E. Progression of wound
Correct Answer: D
Rationale: Poor healing of a pressure injury requires a pressure reduction mattress and wound care nurse consultation, monitoring wound progression and repositioning adherence.
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A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
- A. Fatigue related to disease exacerbation.
- B. Pain related to joint inflammation
- C. Impaired physical mobility related to joint pain.
- D. Self-care deficit related to disease progression.
Correct Answer: B
Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?
- A. Place an indwelling urinary catheter and attach a bedside drainage unit.
- B. Send the client to x-ray for a flat plate of the abdomen.
- C. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- D. Give a prescribed analgesic for temperature above 101° F (38.3°C).
Correct Answer: C
Rationale: An NGT decompresses the stomach, addressing potential bowel obstruction indicated by vomiting and hyperactive bowel sounds.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history indudes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?
- A. Decrease consumption of red meat and most seafood.
- B. Replace dietary table salt with salt substitutes.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Wrap joints with elastic bandage when swollen.
Correct Answer: A
Rationale: Reducing purine-rich foods like red meat and seafood lowers uric acid levels, helping manage gouty arthritis, which likely causes the ankle pain.