Nokea
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.
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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.
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.
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.
How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?
- A. At least every 2 hours
- B. At least every 6 hours
- C. At least every 8 hours
- D. At least every 10 hours
Correct Answer: C
Rationale: When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours.
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.