Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse?
- A. The UAP turns the client every two (2) hours.
- B. The UAP keeps the sheets wrinkle free.
- C. The UAP encourages the client to drink high-protein drinks.
- D. The UAP places multiple diapers on the client.
Correct Answer: D
Rationale: Multiple diapers increase moisture and pressure, worsening stage IV ulcers. Turning, wrinkle-free sheets, and protein drinks are appropriate.
You may also like to solve these questions
Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
- A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Correct Answer: A
Rationale: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.
The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
- A. Keep the skin moist by leaving the skin damp after the bath.
- B. Do not rub any lotion into the skin.
- C. Turn clients who are immobile at least every two (2) hours.
- D. Only the licensed nursing staff may care for the client’s skin.
Correct Answer: C
Rationale: Turning every 2 hours prevents pressure ulcers by relieving pressure. Damp skin risks breakdown, lotion is beneficial, and UAPs can assist with skin care.