Nokea
The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus injury?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: A pressure injury demonstrating blisters is a stage 2 decubitus injury.
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The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails?
- A. Health care provider
- B. RN
- C. CNA
- D. Podiatrist
Correct Answer: D
Rationale: If the patient's nails are extremely hard, a podiatrist should provide care.
Proper hair care is important for the patient's self-image. What is the proper water temperature when shampooing a patient's hair?
- A. 101°F (38.3°C)
- B. 105°F (40.5°C)
- C. 110°F (43.3°C)
- D. 120°F (48.8°C)
Correct Answer: C
Rationale: Water at 110°F (43.3°C) should be used to shampoo a patient's hair.
How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?
- A. At least every 2 hours
- B. At least every 6 hours
- C. At least every 8 hours
- D. At least every 10 hours
Correct Answer: C
Rationale: When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours.
A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?
- A. Heat from pressure
- B. Collapse of blood vessels
- C. Friction from pressure
- D. Collapse of skin tissue
Correct Answer: B
Rationale: A pressure injury occurs when there is sufficient pressure to collapse the blood vessels.
A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes, when taking a sitz bath. What action should the nurse implement?
- A. Cover the patient to prevent chilling.
- B. Stay with the patient until the full time for the bath has elapsed.
- C. Remove the patient from the sitz bath and return to bed.
- D. Assess vital signs every 5 minutes during the remainder of the sitz bath.
Correct Answer: C
Rationale: The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal.