Nokea
Which pressure point area(s) should the nurse monitor for an unconscious client positioned on the left side?
- A. Ankles.
- B. Ear.
- C. Greater trochanter.
- D. Heels.
- E. Occiput.
- F. Sacrum.
- G. Shoulder.
Correct Answer: B,C,D,G
Rationale: On the left side, pressure points include the ear (B), greater trochanter (C), heels (D), and shoulder (G). Ankles, occiput, and sacrum are less affected in this position.
You may also like to solve these questions
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is:
- A. Tolerating the medication well.
- B. Showing addiction to morphine.
- C. Requiring an increased dose.
- D. Experiencing physical dependence.
Correct Answer: C
Rationale: Drug tolerance means the client requires an increased dose to achieve the same pain relief, as the body has adapted to the current dose of morphine.
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend:
- A. Evaluation by a dentist.
- B. Alcohol-based mouth wash rinses.
- C. Artificial saliva.
- D. Vigorous brushing of teeth after each meal.
Correct Answer: C
Rationale: Artificial saliva helps relieve dry mouth and discomfort from stomatitis, a common side effect of head and neck radiation, by maintaining oral moisture.
The most important long-term goal for a client with hypertension would be to:
- A. Learn how to avoid stress.
- B. Explore a job change or early retirement.
- C. Make a commitment to long-term therapy.
- D. Lose weight.
Correct Answer: C
Rationale: Committing to long-term therapy (e.g., medication, lifestyle changes) is critical for sustained blood pressure control and prevention of complications.