Nokea
What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain in a lateral position using protective wrist and vest restraints.
- B. Position prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer to a wheelchair close to the nursing station for observation.
Correct Answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.
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A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
- D. Before changing assignments, determine which staff members have fitted particulate filter masks.
Correct Answer: C
Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.
The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Therefore, documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care.
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?
- A. Ask the wife how she would like to participate in the client's care.
- B. Provide the wife with information about hospice.
- C. Encourage the wife to visit during and after painful treatments are completed.
- D. Refer the wife to a support group for family members of those dying of cancer.
Correct Answer: A
Rationale: During this difficult time of coping with terminal cancer diagnosis, involving the wife in the care process can help her feel more in control and connected. This can be beneficial for both the client and his wife, as it fosters a collaborative approach to care and ensures the wife's needs and preferences are considered.
When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?
- A. Fiber
- B. Folate
- C. Ascorbic acid
- D. Vitamin B12
Correct Answer: D
Rationale: Vitamin B12 is an essential nutrient that is predominantly found in animal products. Since individuals following a vegan diet do not consume animal products, they are at a higher risk of vitamin B12 deficiency. Therefore, it is crucial for vegans to include a vitamin B12 supplement in their dietary plan to prevent deficiency-related health issues.
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.