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The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?
- A. Back-lying
- B. Full lateral
- C. 30-degree lateral
- D. Full prone
Correct Answer: C
Rationale: It is preferable to use the 30-degree lateral incline position.
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The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention?
- A. Cover the area with an occlusive dressing.
- B. Apply mild ointment with a cotton-tipped applicator.
- C. Press the area gently to assess for blanching.
- D. Rub gently to increase circulation.
Correct Answer: C
Rationale: If the area is a stage 1 decubitus injury, the area will not blanch.
The health care provider orders a patient to be placed in the reverse Trendelenburg's position. How should the nurse place the bed?
- A. On the floor
- B. Parallel with the floor
- C. Tilted with the head of the bed down
- D. Tilted with the foot of the bed down
Correct Answer: D
Rationale: The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg's position.
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:
- A. 20 degrees.
- B. 45 degrees.
- C. 90 degrees.
- D. 30 degrees.
Correct Answer: D
Rationale: Elimination is facilitated with the head of the bed elevated 30 degrees.
The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient?
- A. Square position
- B. Long position
- C. Diamond position
- D. Rectangular position
Correct Answer: C
Rationale: Drape the patient with a bath blanket in the diamond position.
The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement?
- A. Speak quickly to the patient.
- B. Speak in loud tones to the patient.
- C. Speak slowly and clearly to the patient.
- D. Tell the patient they must purchase a hearing aid.
Correct Answer: C
Rationale: Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid.