Nokea
The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client
- A. who had an open cholecystectomy and has a closed-wound drainage device
- B. who has a long leg cast and a decreased serum albumin level
- C. with dementia, peripheral artery disease, and constipation
- D. with quadriplegia, moist skin, and an elevated temperature
Correct Answer: D
Rationale: Clients with quadriplegia are at high risk due to immobility, which impairs circulation and increases pressure on skin. Moist skin increases the risk of skin breakdown, and elevated temperature may indicate infection or inflammation, further increasing risk.
You may also like to solve these questions
The nurse is contributing to the plan of care for an 8-year-old client with autism spectrum disorder. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Establish a consistent schedule for providing care.
- B. Encourage the parents to be present when providing care.
- C. Assign the same staff members to care for the client when possible.
- D. Place the client in a private room with familiar belongings.
- E. Use therapeutic touch to comfort the client.
Correct Answer: A,B,C,D
Rationale: Consistency in schedule (A), parental presence (B), familiar staff (C), and a private room with familiar items (D) reduce anxiety in children with autism. Therapeutic touch (E) may be distressing due to sensory sensitivities.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider
- B. Check vital signs
- C. Position in high Fowler's
- D. Administer oxygen
Correct Answer: D
Rationale: Administer oxygen. In a medical emergency, airway and breathing are prioritized. Oxygen administration addresses the immediate respiratory distress.
The nurse is caring for a client who is experiencing status epilepticus and does not have a peripheral venous access device. Which of the following actions should the nurse take first?
- A. Administer rectal diazepam.
- B. Transport the client for a CT scan.
- C. Obtain a blood specimen for complete blood count.
- D. Check the client for neck stiffness and Brudzinski sign.
Correct Answer: A
Rationale: Rectal diazepam is a first-line treatment for status epilepticus when IV access is unavailable, as it rapidly terminates seizures to prevent brain damage.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
- A. You should cancel your upcoming business trip.
- B. Your spouse should come to the clinic today to be assessed.
- C. It sounds like you are having a difficult time coping with your spouse's behavior.
- D. It is best to ignore your spouse's behavior because your spouse is doing this to gain attention.
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.