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The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
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The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client's PEG tube was changed 6 months ago.
- D. The client's indwelling urinary catheter was last changed 5 days ago.
Correct Answer: A
Rationale: Bedridden clients should be repositioned every 2 hours to prevent skin breakdown.
The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action?
- A. Resume the urine collection and collect one additional voided specimen.
- B. Discard the urine collected and begin a new urine collection immediately.
- C. Complete the urine collection and send all urine collected to the laboratory.
- D. Dispose of the urine collected and reschedule the test to begin the next morning.
Correct Answer: B
Rationale: B: A discarded void invalidates the collection; restarting ensures accuracy. A: Adding a void causes inaccuracies. C: Missing a void compromises results. D: Rescheduling is unnecessary as the test can start anytime.
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.
A hospital discharge planning nurse is making arrangements for a client who has an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility
Correct Answer: B
Rationale: Transferring to a facility unprepared for epidural catheter management risks client safety. Finding a capable facility ensures continuity of care.
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.