RN Nursing Basic Care and Comfort

RN Nursing Basic Care and Comfort Related

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The nurse is caring for a group of clients in a medical/surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers?

  • A. a 27-year-old client who fractured her arm playing volleyball
  • B. a 6-year-old client on pelvic skin traction for muscle spasms
  • C. a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair
  • D. a 70-year-old client with heart failure who uses a cane for ambulation in the room and hall
Correct Answer: C

Rationale: The obese client in a wheelchair (C) has prolonged pressure and reduced mobility, increasing decubitus ulcer risk. Arm fracture (A), traction (B), and ambulatory client (D) have lower risk.

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The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse?

  • A. take the infant's vital signs
  • B. order a neurology consult
  • C. examine the infant's nose and ears
  • D. ask how much formula the infant consumes daily
Correct Answer: B

Rationale: No movement in response to the Babinski reflex (fanning toes) at six months suggests neurological abnormality, warranting a neurology consult (B). Other actions (A, C, D) are less urgent.

The nurse is caring for a client with fluid overload who is on strict I's and O's. The nurse understands that which is the best way to ensure accurate I's and O's?

  • A. clear any IV pumps and reset to zero for accurate IV fluid intake
  • B. ask the client to keep up with how many cups of fluid he drinks at meals
  • C. ask the client to report how much urine is in the urinal each time he uses it
  • D. tell the client not to ask for any extra water or drinks that are not on the meal tray
Correct Answer: A

Rationale: Accurate I's and O's require nurse measurement of all fluids, including IVs and oral intake, and urine output, typically using graduated containers. None of the options fully ensure accuracy, as they rely on client reporting or incomplete measures.

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