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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.
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Because of its effect on epithelization the LPN/LVN should confirm the order to use ____ or alcohol on a stage 3 pressure injury.
Correct Answer: peroxide
Rationale: Peroxide and alcohol have a negative effect on epithelization of a pressure injury.
Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?
- A. Upward toward the forehead
- B. Downward toward the chin
- C. From the outer toward the inner canthus
- D. From the inner toward the outer canthus
Correct Answer: D
Rationale: The eye is cleansed from the inner to outer canthus.
The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
- A. Every 30 minutes
- B. Every 60 minutes
- C. Every 120 minutes
- D. Every 180 minutes
Correct Answer: C
Rationale: The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time.
When must the nurse remember to use an electric razor when shaving a patient?
- A. When a bleeding tendency is present
- B. When there is a risk for suicide
- C. When the facial hair is fine
- D. When speed is essential
Correct Answer: A
Rationale: A patient with a bleeding disorder should use an electric razor.
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.