Nokea
The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
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Which health teaching information is most appropriate for a client with a herpes simplex virus type 1 infection?
- A. Apply petroleum jelly to the lesions to prevent spreading the virus to adjacent areas.
- B. Use good personal hygiene to prevent spreading the virus to other body parts.
- C. Avoid using soap and water on open lesions.
- D. Remove the scabs daily by soaking with hot compresses.
Correct Answer: B
Rationale: Good hygiene prevents viral spread to other areas.
Before leaving the room, which of the following nursing access to the nurse's place, the client's place.
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
The client with the condition illustrated is prescribed adapalene topical daily to the affected areas. Which information should the nurse exclude when planning client education?
- A. The client has acne vulgaris, an inflammatory disease involving the sebaceous glands of the skin characterized by papules or pustules or comedones.
- B. Adapalene should be applied once daily in the evening.
- C. Exposing the back to the sun after adapalene (Differin) is applied.
- D. Only a thin film of adapalene should be applied.
Correct Answer: C
Rationale: The nurse should exclude exposing the back to the sun after adapalene (Differin) is applied. This increases the risk for sunburn. Adapalene should also not be applied to sunburned areas. The client has acne vulgaris. Adapalene should be applied once daily in the evening with a thin film.
The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?
- A. Padding the client's sacrum and heels
- B. Obtaining an alternating air pressure mattress
- C. Using a lifting device when turning the client
- D. Keeping the head of bed lower than 30 degrees
Correct Answer: D
Rationale: Keeping the HOB higher than 30 degrees increases the shearing forces to the shoulders, sacrum, and heels. Padding and air mattresses reduce tissue pressure but not shearing forces. Using a lift sheet helps reduce friction but not shearing forces.
The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL X weight in kg X % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? mL of IV fluid (Record your answer as a whole number.)
- A. 4000
Correct Answer: A
Rationale: Use the Parkland formula provided: 4.0 mL at 50 kg = 200 mL; 200 mL × 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn.