Nokea
The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the healthcare team use for logrolling?
- A. Involve at least three to four people.
- B. Instruct the patient not to reach for the opposite side rail when turning.
- C. Move the bottom part of the patient's torso first and then the top part.
- D. Use pillows for support before turning.
Correct Answer: A
Rationale: The correct technique for logrolling involves at least three to four people to ensure the safety and proper alignment of the patient's spine. Logrolling requires coordinated effort from multiple individuals to prevent twisting or bending of the spine, hence option A is correct. Option B is incorrect as patients with spinal cord injuries should not be instructed to reach for the opposite side rail due to the risk of causing harm. Option C is incorrect as moving the bottom part of the patient's torso first could lead to spinal misalignment. Option D is incorrect as pillows should be used for support and comfort after the patient has been successfully turned, not before.
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A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?
- A. Assess the client's perineum
- B. Administer pain medication
- C. Clean the area with a mild cleanser
- D. Apply a barrier cream to the affected area
Correct Answer: A
Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?
- A. INR of 1.5
- B. Platelet count of 200,000/mm³
- C. Hemoglobin of 12 g/dL
- D. aPTT of 70 seconds
Correct Answer: A
Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.
During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?
- A. Stringy, white tissue
- B. Translucent, red tissue
- C. Soft, yellow tissue
- D. Thick, black tissue
Correct Answer: B
Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?
- A. Consult the medication reference book available on the unit.
- B. Administer the medication as ordered.
- C. Ask a colleague for information about the medication.
- D. Contact the provider to clarify the medication.
Correct Answer: A
Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
- B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse
Correct Answer: C
Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.