Nokea
The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply.
- A. Pronounced wrinkles on the face
- B. Decreased size of the nose and ears
- C. Increased growth of facial hair
- D. Neck wrinkles
- E. Increased height
Correct Answer: A, C, D
Rationale: Aging causes pronounced wrinkles on the face and neck and increased facial hair due to hormonal changes. Nose and ears enlarge, and height decreases due to spinal compression.
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Which of the following accurately summarizes the primary purpose of skin care and hygiene?
- A. Maintain skin sterility and prevent infection
- B. Prevent bodily odors by eliminating bacteria
- C. Protect the body's first line of defense
- D. Provide the client with comfort and well-being
Correct Answer: C
Rationale: The skin is the body's first line of defense against pathogens and injury, and proper skin care maintains its integrity.
Place the following actions in the order in which they need to be performed, starting with the highest priority action.
- A. Initiate a large-bore peripheral vascular access device
- B. Perform a respiratory assessment and inspect the client's nose and mouth
- C. Administer prescribed intravenous (IV) pain medication
- D. Administer prescribed intravenous (IV) fluids
- E. Perform wound care to the affected area(s)
Correct Answer: B, A, D, C, E
Rationale: Respiratory assessment is first to ensure airway patency, followed by IV access and fluids for resuscitation, pain medication for comfort, and wound care last.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 5 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse should plan to obtain a prescription for ………………….. to restore circulating volume. The ……………………… will be used to determine the 24-hour fluid requirement. To measure the effectiveness of the fluid replacement, the nurse plans to …………………………..
- A. 0.45% saline
- B. Dextrose 5% Water (D5W)
- C. Lactated ringers
- D. Parkland formula
- E. pulmonary function tests
- F. TNM staging
- G. insert an indwelling urinary catheter
Correct Answer: C, D, G
Rationale: Lactated Ringers restores circulating volume, the Parkland formula calculates fluid needs, and a urinary catheter monitors output to assess fluid replacement effectiveness.
Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.
- A. Applies zinc oxide to the client's perineal skin
- B. Provides a donut pillow while the client is sitting in the chair
- C. Maintain the head of the client's bed at 90 degrees
- D. Encourages the client to consume foods rich in carbohydrates
- E. Uses a pillow to float the client's heels
Correct Answer: B, C
Rationale: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.
Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.
- A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'
- B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'
- C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'
- D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'
- E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'
Correct Answer: A, C
Rationale: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.