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The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
- A. Apply a lubricating lotion to the skin.
- B. Pad all bony prominences.
- C. Encourage a high protein diet.
- D. Bathe with a mild soap daily.
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.
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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Tennis shoes with velcro.
- B. Rubber-soled slippers.
- C. Slip-on rubber shower shoes.
- D. Leather-soled loafers.
Correct Answer: A
Rationale: Velcro tennis shoes provide support and stability.