Nokea
Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.
You may also like to solve these questions
The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
- A. Positioning the client lying down to remove the prosthetic eye
- B. Drying the prosthetic eye with gauze before reinsertion
- C. Cleansing the prosthetic eye with normal saline solution
- D. Telling the client to remove the prosthetic eye weekly for cleaning
Correct Answer: B
Rationale: B: The prosthetic eye should be moist to facilitate insertion; drying it could cause trauma to the socket. A: Lying down aids safe removal. C: Normal saline is appropriate for cleansing. D: Periodic removal every 1-3 weeks is recommended.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.
In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?
- A. Blood urea nitrogen
- B. Serum calcium
- C. Serum ammonia
- D. Serum creatinine
Correct Answer: C
Rationale: Elevated serum ammonia is critical in hepatic coma, as liver failure impairs ammonia metabolism, causing brain-tissue irritation.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.