Nokea
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.
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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.
The nursing assessment of a pressure injury includes size depth pain odor and color of tissue. What does this evaluate?
- A. Treatment needed
- B. Effectiveness of implementation
- C. Whether improvement is occurring
- D. Need for additional interventions
Correct Answer: C
Rationale: Ongoing assessment of a pressure injury will evaluate whether improvement is occurring.
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.
The nurse is preparing to bathe a patient. What should the room temperature be set at?
- A. No warmer than 67°F (19.4°C)
- B. No cooler than 68°F (20°C)
- C. No cooler than 70°F (21.1°C)
- D. 75°F or warmer (23.8°C)
Correct Answer: B
Rationale: The recommended room temperature is 68° to 74°F (20° to 23.3°C).
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.