Nokea
The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply.
- A. Apply moisture barrier cream to dry skin
- B. Clean perineal area after incontinent episodes
- C. Massage bony prominences frequently
- D. Place foam-padded seat cushions on chairs
- E. Reposition clients in bed every 6 hours
Correct Answer: A,B,D
Rationale: Moisture barrier cream protects skin, cleaning after incontinence prevents irritation, and foam cushions reduce pressure. Massaging bony prominences can cause tissue damage, and repositioning every 6 hours is too infrequent; every 2 hours is standard.
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A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child?
- A. Gastrointestinal bleeding
- B. Growth retardation
- C. Neurocognitive impairment
- D. Severe liver injury
Correct Answer: C
Rationale: Elevated lead levels primarily cause neurocognitive impairment in children, affecting brain development and leading to learning and behavioral issues. Gastrointestinal bleeding, growth retardation, and liver injury are less common or less severe consequences.
Which comment by the client is most significant in light of the fact that he has Ménière's disease?
- A. I take a walk every day.
- B. I listen to my iPOD a lot.
- C. I smoke a pack of cigarettes a day.
- D. It is very noisy at my workplace.
Correct Answer: C
Rationale: Cigarette smoking has been shown to aggravate Ménière's disease. The client will be told to stop smoking to decrease the frequency and severity of Ménière's. Walking, listening to an IPOD or other electronic device, and exposure to noise have not been shown to be related to Ménière's disease.
The nurse is talking with a client with obesity who has a new prescription for a lipase inhibitor. Which of the following statements by the client would require follow-up?
- A. I will take this medication in the morning on an empty stomach.
- B. I should consume a diet that is low in fat while taking this medication.
- C. I may experience oily stools and flatulence while taking this medication.
- D. I will take fat-soluble vitamins at least 2 hours before or after taking this medication.
Correct Answer: A
Rationale: Lipase inhibitors like orlistat should be taken with or within an hour of meals containing fat, not on an empty stomach, to effectively block fat absorption. The other statements are correct: low-fat diet minimizes side effects, oily stools and flatulence are common, and vitamins should be timed to avoid malabsorption.
The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. Do not sit on toilet seats without protection.'
- B. Oral sex does not transmit the virus.'
- C. This infection can be transmitted via intercourse even when you do not feel ill.'
- D. Try to drink lots of fluids after sex to flush the reproductive tract.'
Correct Answer: C
Rationale: Genital herpes can be transmitted during asymptomatic periods via sexual contact, including intercourse. The other statements are myths or irrelevant to prevention. Safety and Infection Control
An adult is admitted to the hospital with several days of vomiting and diarrhea. Admitting data show RBC level of 4.2 million/mm³ and hematocrit of 54%. What is the best interpretation of these data?
- A. The client may have internal bleeding.
- B. The client is probably dehydrated.
- C. These are normal findings.
- D. The client is anemic.
Correct Answer: B
Rationale: Elevated hematocrit (normal: 36-46% for females, 41-53% for males) with normal RBC suggests hemoconcentration from dehydration due to fluid loss from vomiting and diarrhea.