Nokea
When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?
- A. Massage the reddened area.
- B. Apply a donut-shaped cushion.
- C. Reposition the client every 3 hours.
- D. Use a transparent film dressing.
Correct Answer: D
Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.
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When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?
- A. Shake the inhaler before use.
- B. Inhale quickly and deeply.
- C. Use the inhaler as needed.
- D. Do not use a spacer with the inhaler.
Correct Answer: A
Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.
During discharge instructions, a client with a new prescription for a metered-dose inhaler (MDI) states, 'I will shake the inhaler before each use.' Which of the following client statements indicates an understanding of the teaching?
- A. I will shake the inhaler before each use.
- B. I will use the inhaler immediately after meals.
- C. I will inhale the medication quickly.
- D. I will clean the mouthpiece with alcohol.
Correct Answer: A
Rationale: The correct answer is A because shaking the inhaler before each use ensures that the medication is properly mixed, which is essential for effective administration. This action helps to disperse the medication evenly, enhancing its efficacy when inhaled. Proper mixing through shaking prevents inconsistent dosing and ensures that the client receives the correct amount of medication with each use.
What action is required by law when preparing to administer a controlled substance?
- A. Verify the client's identification using two identifiers.
- B. Document the medication administration in the client's chart immediately.
- C. Return any unused portion of the medication to the pharmacy.
- D. Have a second nurse witness the disposal of any unused portion.
Correct Answer: D
Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.
What is a true statement about caring for a client with a nasogastric (NG) tube?
- A. The NG tube should be flushed with 30 mL of water every 4 hours.
- B. The client should be positioned in a supine position.
- C. The NG tube should be advanced 5 cm if resistance is met.
- D. The client's nasal mucosa should be inspected daily.
Correct Answer: A
Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.
What action should a healthcare provider take for a client with a new colostomy?
- A. Empty the colostomy bag when it is half full.
- B. Place aspirin in the colostomy bag to decrease odor.
- C. Use sterile technique when caring for the stoma.
- D. Change the pouch every 8 hours.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.