Nokea
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.
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Which guideline should be followed when giving a backrub?
- A. Observing the skin for abnormalities
- B. Massaging for at least 10 minutes
- C. Following massage with a brisk alcohol rub
- D. Conversing with patient continually throughout the backrub
- E. Using alcohol-based lotion for disinfection
Correct Answer: A
Rationale: The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin.
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.
As a safety precaution against breakage of dentures the nurse should place ____ in the emesis basin before cleaning the dentures.
Correct Answer: water
Rationale: Water in the basin will break the fall of the dentures if they are dropped.
To prevent skin breakdown in a wheelchair-bound patient the nurse teaches the patient to shift the patient's weight every ____ minutes.
Correct Answer: 15
Rationale: People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown.
What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient?
- A. Nurse's orders
- B. Health care provider's orders
- C. Patient's preferences
- D. Outcome goals
Correct Answer: C
Rationale: Individual patients will have individual desires and choices.