Nokea
The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?
- A. Burn
- B. Laceration
- C. Pressure injury
- D. Infection
Correct Answer: C
Rationale: A major manifestation of impaired skin integrity is a pressure injury.
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The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient?
- A. Nursing care
- B. Independence
- C. Repetition
- D. Performance
Correct Answer: B
Rationale: The nurse should encourage the patient's independence as much as possible.
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 bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?
- A. Washing the leg with long firm strokes and drying with a towel
- B. Omitting washing the leg at all
- C. Gently washing the leg and patting dry with a towel
- D. Applying lotion in long smooth strokes
Correct Answer: C
Rationale: The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging.
How will the nurse correctly replace a patient's dentures after cleaning?
- A. Inserting the lower denture first
- B. Asking the patient to insert them
- C. Inserting both dentures together
- D. Inserting the upper denture first
Correct Answer: D
Rationale: When reinserting dentures, replace the upper dentures first.
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.