Nokea
During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Discusses the client's need for a nutrient-rich, high-calorie diet with the dietician
- B. Documents the impaired skin as an unstageable pressure injury in the client's medical record
- C. Gently cleanses the impaired skin with normal saline and pats the area dry with gauze
- D. Places a hydrophilic dressing over the impaired skin after performing wound care
- E. Repositions the client frequently and avoids putting pressure on the impaired skin
Correct Answer: A,C,D,E
Rationale: A nutrient-rich diet (A) supports wound healing. Cleansing with saline (C) prevents infection. A hydrophilic dressing (D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.
You may also like to solve these questions
An adult is receiving nasal oxygen at 6 L/min. The client asks the nurse why the oxygen is humidified. What should the nurse include when responding to the client?
- A. Humidifying oxygen helps to prevent fire.
- B. Humidity increases the concentration of oxygen.
- C. Humidity helps to keep the nasal passages from drying out.
- D. Humidity reduces the growth of organisms in the tubing.
Correct Answer: C
Rationale: Humidification prevents nasal mucosal drying and discomfort at higher oxygen flow rates like 6 L/min, not fire prevention, concentration increase, or bacterial reduction.
The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity?
- A. Encouraging use of puzzles for play
- B. Offering the child stacking blocks for diversion
- C. Providing crayons to draw noses on facemasks
- D. Suggesting that playmates visit the child
Correct Answer: C
Rationale: Drawing on facemasks is an age-appropriate, creative activity that promotes self-expression and reduces fear associated with medical equipment, supporting psychosocial integrity.
The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?
- A. 51-year-old client who received a permanent pacemaker 48 hours ago
- B. 60-year-old client who had a myocardial infarction 24 hours ago
- C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
- D. 75-year-old client with dementia and dehydration who is on IV fluids
Correct Answer: C
Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
- A. UAP has attached a bed alarm to the client's gown and bed
- B. UAP has been making hourly rounds on the client
- C. UAP has lowered the bed and raised all 4 side rails
- D. UAP has placed a fall risk ID bracelet on the client's wrist
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
- A. Vancomycin trough 10 mg/L (6.9 umol/L), creatinine 1.1 mg/dL (97.2 umol/L), BUN 6 mg/dL (2.1 mmol/L)
- B. Vancomycin trough 14 mg/L (9.7 umol/L), creatinine 1.2 mg/dL (106.1 umol/L), BUN 10 mg/dL (3.6 mmol/L)
- C. Vancomycin trough 18 mg/L (12.4 umol/L), creatinine 0.6 mg/dL (53 umol/L), BUN 18 mg/dL (6.4 mmol/L)
- D. Vancomycin trough 23 mg/L (15.9 umol/L), creatinine 1.5 mg/dL (132.6 umol/L), BUN 24 mg/dL (8.6 mmol/L)
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.