Nokea
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
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The client with dementia and confusion is transferred from the hospital to the nursing home. The client's family has not yet arrived at the nursing home. Which direction is appropriate for the RN to provide to the LPN?
- A. "Take a photograph of the new resident; it is needed to administer medications."
- B. "Place the person in a wheelchair near the nurse's station until the family arrives."
- C. "Help the new resident change into clothing with Velcro closures for easy removal."
- D. "Perform a full-body assessment and document this in the resident's medical record."
Correct Answer: B
Rationale: Placing the client near the nurse's station ensures supervision and safety for a client with dementia, who is at risk for falling or wandering.
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
- A. Get temperatures
- B. Take blood pressure
- C. Palpate pulses
- D. Check alertness
Correct Answer: C
Rationale: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube system
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct Answer: C
Rationale: The PN is a licensed provider and can perform this complex task. Irrigating and redressing a leg wound requires clinical skills appropriate for a PN, whereas the other tasks are either simpler or require an RN.
Which of these actions should the nurse perform first when a client is admitted with a diagnosis of C-difficile?
- A. Initiate contact precautions
- B. Administer prescribed antibiotics
- C. Obtain a stool culture
- D. Educate the client about hand hygiene
Correct Answer: A
Rationale: Initiating contact precautions is the first step to prevent the spread of C-difficile, which is highly contagious through contact with contaminated surfaces or feces.
The nurse is evaluating the performance of the UAP. The nurse should provide feedback to the UAP about which unsafe action?
- A. Cleanses and returns a wheelchair to a storage area after being used by the client.
- B. Ties the bedridden client's wrist restraint ties to the bed frame using a quick-release knot.
- C. Grasps the cord to unplug an intravenous infusion pump for the client's transport to x-ray.
- D. Turns on a bed exit alarm for the confused client who was talking incoherently to the UAP.
Correct Answer: C
Rationale: Grasping the cord to unplug the pump can damage the cord, increasing the risk of electrical shock, requiring feedback to the UAP.