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: The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary
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What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
- A. Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.
- B. Activity level is determined by the client's tolerance; she can be as active as she wishes.
- C. Activity level will be restricted for several months, so she should plan on being sedentary.
- D. Activity level can return to normal and may include regular aerobic exercises.
Correct Answer: A
Rationale: Gradual resumption of activity over 5 to 6 weeks allows the retina to heal properly while minimizing the risk of re-detachment or complications.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
- A. Discontinue the PCA pump.
- B. Administer oxygen.
- C. Take the client's blood pressure.
- D. Assist the client back to bed.
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.