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When educating unlicensed assistants on how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by implementing which of the following activities?
- A. Close adherence to a turning schedule
- B. Keeping the skin clean and dry
- C. Proper positioning and moving of the client
- D. Use of skin lubricants
Correct Answer: C
Rationale: Proper positioning and moving techniques prevent shearing injuries, which occur when skin slides over a surface, damaging tissue. Turning schedules and clean skin help but are less specific to shearing.
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The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
- A. Ask the client his name.
- B. Check the client's name band.
- C. Straighten the client's pillow behind his back.
- D. Give the client his medications.
Correct Answer: C
Rationale: Repositioning the client first ensures comfort and safety, addressing the immediate issue of the awkward position before administering medications.
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician orders 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
- A. Crackles in the lung bases.
- B. Blood pressure elevation.
- C. Cerebral edema.
- D. Cool skin temperature in lower extremities.
Correct Answer: B
Rationale: Albumin increases oncotic pressure, pulling fluid into the vascular space, which may elevate blood pressure. Crackles, cerebral edema, or cool extremities would indicate complications.
A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for:
- A. Irritability.
- B. Hyperventilation.
- C. Diarrhea.
- D. Edema.
Correct Answer: B
Rationale: Persistent vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, which can manifest as hyperventilation as the body compensates for elevated pH.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which recommendation is appropriate?
- A. Eat large meals to reduce acid production
- B. Sleep flat to promote digestion
- C. Avoid lying down for 2 hours after eating
- D. Drink coffee to relax the esophagus
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by allowing gravity to keep stomach contents in place.
A client with cirrhosis reports itching. Which intervention should the nurse implement?
- A. Apply a heating pad.
- B. Administer an antihistamine.
- C. Encourage a hot shower.
- D. Apply a moisturizing lotion.
Correct Answer: D
Rationale: Moisturizing lotion relieves itching in cirrhosis by hydrating dry skin without exacerbating symptoms.