Nokea
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
- A. Reinforce the aide's use of this intervention over the bony prominences.
- B. Explain that massage is effective because it improves blood flow to the area.
- C. Inform the aide that massage is even more effective when combined with lotion during the massage.
- D. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.
You may also like to solve these questions
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
- A. Taking sitz baths several times a day.
- B. Applying a moist heat pack to the wound.
- C. Performing perineal irrigations.
- D. Packing the wound with sterile gauze.
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.
Which fluid is best for a client with renal calculi?
- A. Cranberry juice.
- B. Cola.
- C. Water.
- D. Milk.
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?
- A. Applying moist heat to the flank area.
- B. Administering meperidine (Demerol).
- C. Encouraging high fluid intake.
- D. Maintaining complete bed rest.
Correct Answer: B
Rationale: Meperidine, an opioid, provides the most effective relief for the severe pain of renal colic by directly addressing pain pathways.