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The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
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Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
- A. Abdominal girth.
- B. Breath sounds.
- C. Bowel sounds.
- D. Vital signs.
Correct Answer: D
Rationale: Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client's vital signs. This includes checking the client's blood pressure, pulse rate, respiratory rate, and temperature. These measurements can provide important information about the client's overall health status and can help the nurse determine if it is safe to proceed with the procedure.
What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?
- A. 3 mL syringe and a sterile needle.
- B. One ounce medicine cup.
- C. 3 mL syringe.
- D. Tuberculin syringe.
Correct Answer: C
Rationale: A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.
Which response by the nurse is most therapeutic?
- A. Tell me about the visit with your significant other.
- B. I can see that you are feeling lonely.
- C. Would you like to talk for a while?
- D. What did you enjoy about your visit tonight?
Correct Answer: C
Rationale: This response shows that the nurse is willing to listen and provide support to the client. It also allows the client to decide if they want to talk and share their feelings.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.