Nokea
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
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The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
- A. Morphine 2.0 mg IV every four hours for severe pain.
- B. Morphine 2 mg IV every 4 hr PRN for severe pain.
- C. IV MS 2 mg every 4 hr as needed for severe pain.
- D. IV MS 2.0 mg every 4 hours PRN for severe pain.
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
- A. Ask an unlicensed assistive personnel to stay with the client.
- B. Place the bedpan within the reach of the client.
- C. Obtain a bedside commode for the client to use.
- D. Notify the healthcare provider of the client's concerns.
Correct Answer: C
Rationale: Commode prevents enema expulsion accidents.
History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
- A. Gather materials to change soiled items only;
- B. Thoroughly clean wound using normal saline prior to redressing;
- C. Place sterile gauze directly on wound bed;
- D. Apply sterile gloves prior to changing;
- E. Apply sterile foam dressing over wound bed;
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.
The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Review the intake and output record.
- B. Give the client 8 ounces of water to drink.
- C. Notify the healthcare provider.
- D. Check the drainage tubing for a kink.
Correct Answer: D
Rationale: Checking for kinks ensures catheter functionality.
The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
- A. Use firm pressure to pass the tube through the glottis.
- B. Have the client tilt head backward to open the passage.
- C. Give the client a few sips of water to drink.
- D. Remove the tube and attempt reinsertion.
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.