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Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
- A. The technique is intended to maintain straight spinal alignment.
- B. Working together can decrease the risk of back injury to the nurses.
- C. Using two or three people increases client safety.
- D. Turning instead of pulling reduces the likelihood of skin damage.
Correct Answer: A
Rationale: Log rolling maintains spinal alignment for safety.
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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. This must be a very difficult time for you.'
- B. You did nothing wrong.'
- C. With surgery, your baby should have a full recovery.'
- D. Is there any particular reason why you think this is your fault?'
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
- A. Hypothyroidism.
- B. Hypertension.
- C. Peptic ulcer disease.
- D. Fibromyalgia.
Correct Answer: B
Rationale: Sleep apnea increases hypertension risk due to oxygen desaturation.
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.
The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
- A. Apply a lubricating lotion to the skin.
- B. Pad all bony prominences.
- C. Encourage a high protein diet.
- D. Bathe with a mild soap daily.
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.