Try Naxlex NCLEX-RN (Free-Trial)

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Massage over erythematous bony prominences.

Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface.

Implement a turning schedule every 4 hours.

Keep the client's skin dry with powder.

Answer and Explanation

Correct Answer : B,C

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason:
Using chemotherapy instead of radiation may not be a viable option as the treatment plan is based on the type and stage of cancer. Chemotherapy can also affect fertility, so it is not a direct solution to the concern of infertility.

Choice B reason:
Fertility medications during treatment might help preserve fertility, but they do not address the direct impact of radiation on reproductive organs. Additionally, the use of such medications should be discussed with an oncologist and a fertility specialist.

Choice C reason:
Radiation shielding techniques involve using protective shields to limit radiation exposure to the reproductive organs. This can help reduce the risk of infertility caused by radiation, especially when the pelvic area is involved in the treatment.

Choice D reason:
Surgical interventions to remove the cancer may be part of the treatment plan, but they do not directly address the concern of radiation-induced infertility. Surgery can also result in infertility, depending on the organs involved and the extent of the procedure.

A. Who was the individual who assaulted you? B. What day and time did the assault take place? C. Where did the assault occur? D. Do you give us permission to call the police?

Correct Answer is B

Explanation

Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.

Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.

Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.

Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client who was recently diagnosed with cancer and tells the nurse they are worried about infertility following radiation treatment. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

Which of the following questions is most important to ask a client who might have been exposed to HIV after being sexually assaulted?

Correct Answer is B

Explanation

A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?

A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make?

A nurse is caring for a 68-kg (150-lb) client who has dehydration. Which of the following manifestations is an indication of effective treatment?

A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis?