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The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
- A. Staff documentation of turning the patient every 2 hours
- B. Presence of redness only on the heels of the patient
- C. Patient’s eating 100% of all meals NursingStoreRN
- D. Absence of skin breakdown
Correct Answer: D
Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.
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Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply
- A. Offer the opposite breast at each feeding to their
- B. Avoid frequent nursing of the infants
- C. Avoid breastfeeding
- D. Ensure that their hands and breasts are clean
Correct Answer: D
Rationale: Rationale:
D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses.
A is incorrect because alternating breasts is a common practice in breastfeeding.
B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis.
C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
- A. Make sure his oxygen is being administered as ordered.
- B. Have him breathe into a paper bag.
- C. Place him in a semi-fowler’s position.
- D. Have him do coughing and deep breathing exercises.
Correct Answer: B
Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms.
Incorrect choices:
A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels.
C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation.
D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
- A. Terminate the plan of care
- B. Modify the plan of care
- C. Reassign care to another nurse
- D. Reassess the client’s condition
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome.
Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success.
Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step.
Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
Mr. Reyes has a possible skull fracture. The nurse should:
- A. Observe him for signs of Brain injury
- B. Check for hemorrhaging from the oral cavity
- C. Elevate the foot of the bed if he develops symptoms of shock
- D. Observe for symptoms of decreased intracranial pressure and temperature
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.