Nokea
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply.
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours.
- E. Request an alternating-pressure mattress.
Correct Answer: C,D,E
Rationale: Protective dressings, frequent repositioning, and pressure-relieving mattresses promote healing and prevent worsening of pressure ulcers. High head elevation increases shear, and daily cultures are unnecessary unless infection is suspected.
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Which of the following should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply.
- A. Diminished hair on scalp and pubic areas.
- B. Dusky rubor of left lower extremity.
- C. Solar lentigo.
- D. Wrinkless.
- E. Yellow pigmentation.
Correct Answer: A,C,D
Rationale: Normal aging includes diminished hair, solar lentigo (age spots), and wrinkles. Dusky rubor suggests vascular issues, and yellow pigmentation may indicate jaundice, not normal aging.
A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. The nurse is preparing preoperative teaching. Which of the following should be included in the teaching plan to address potential changes in sexuality?
- A. Sexual intercourse will not be possible after surgery.
- B. Vaginal dryness may occur, and water-soluble lubricants can help.
- C. Menopausal symptoms will not occur if ovaries are preserved.
- D. Sexual desire will remain unchanged after surgery.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect after hysterectomy due to changes in vaginal tissue and potential hormonal shifts, even if ovaries are preserved. Teaching about water-soluble lubricants helps the client prepare for and manage this change.
Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
- A. Nasogastric drainage.
- B. Urinary catheter.
- C. Dressing.
- D. Need for pain medication.
Correct Answer: C
Rationale: After a splenectomy, the nurse should assess the dressing for signs of bleeding, as the spleen is highly vascular, and postoperative hemorrhage is a risk. Nasogastric drainage, urinary output, and pain are assessed later, but the dressing is the priority to detect complications.