Nokea
The nurse will be using the Braden Scale with each admit to the long-term care
center. Which of these will NOT be utilized in a Braden Scale Assessment?
- A. Mental state
- B. Friction and shear
- C. Nutrition
- D. Sensory perception
Correct Answer: A
Rationale:
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The client states, "Why am I getting protein supplements while I am healing
from a bed sore?"? What is the best response by the nurse?
- A. Because it is easy to digest.'
- B. Protein has amin acid that promotes wound healing.'
- C. If you do not like it, you do not have to take it.'
- D. These supplements have nothing to do with your wound,'
Correct Answer: B
Rationale:
The nurse is caring for 4 clients. What client should the nurse see first?
- A. A client with multiple children visiting
- B. A client with lupus asking for dinner
- C. A client on Methotrexate with a fever
- D. A client with chronic rheumatic pain
Correct Answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
A client has sustained an open fracture. How can the nurse best prevent
osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct Answer: B
Rationale:
Which among the following is NOT the cause of pressure ulcers?
- A. Immobility
- B. Poor nutrition
- C. Moisture
- D. Adequate perfusion
Correct Answer: D
Rationale:
What is the priority intervention for the nurse to enhance meeting the
psychosocial needs of a client on transmission-based precautions?
- A. Allow the client sleep to build stamina
- B. Provide the client with diversional activities
- C. Maintain a six-foot distance from the client
- D. Provide a timeframe for the isolation
Correct Answer: B
Rationale: