An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

Apply lotion to sacrum.

Use wet-to-dry dressings daily.

Elevate head of bed 30 degrees.

Change positions every 2 hours.

Answer and Explanation

The Correct Answer is D

A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Show acceptance of the client's current feelings: Accepting the client’s emotional response without judgment builds trust and provides emotional support, which is critical when coping with a new diagnosis of advanced cancer.
B. Share a similar personal experience: Sharing personal experiences shifts the focus away from the client’s feelings and can be perceived as minimizing their unique emotional response. It is more therapeutic to focus entirely on the client’s experience.
C. Document the behavior in the client's record: Accurate documentation of the client's emotional state ensures continuity of care and alerts other healthcare providers to the client's need for emotional support and potential interventions.
D. Ask the palliative care nurse to see the client: Involving a palliative care specialist provides expert emotional, spiritual, and symptom management support, which is appropriate for a client newly diagnosed with stage IV cancer.
E. Allow the client a time to continue crying: Allowing the client to cry acknowledges their need to express grief and emotion. It helps the client begin processing the overwhelming news and supports healthy emotional expression.

A. Notify the charge nurse. B. Reposition the oximeter clip. C. Document the conflicting data. D. Measure the blood pressure.

Correct Answer is B

Explanation

A. Notify the charge nurse: Notifying the charge nurse would be appropriate if the discrepancy persists after troubleshooting. However, first steps should involve checking the equipment to rule out technical errors before escalating the concern.
B. Reposition the oximeter clip: A discrepancy between the manual pulse and the pulse oximeter reading often indicates a technical issue, such as poor sensor placement or poor perfusion. Repositioning the oximeter clip ensures accurate data collection before proceeding with further interventions.
C. Document the conflicting data: Documentation is important, but before recording inconsistent or potentially inaccurate findings, the nurse should first validate the data by ensuring correct technique and equipment function.
D. Measure the blood pressure: Measuring blood pressure is part of a full vital signs assessment but does not address the immediate concern of conflicting pulse readings. Equipment issues must be corrected first to ensure all vital signs are accurate.

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An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is recently diagnosed with stage IV ovarian cancer tells the practical nurse (PN) that the staff on the unit are insensitive and begins to cry. Which intervention(s) should the PN implement? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

During vital sign assessment of a client, the practical nurse (PN) counts the left radial pulse at 88 beats/minute, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 beats/minute with an oxygen saturation of 95%. Which of the following should the PN do first?

Correct Answer is B

Explanation

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

The practical nurse (PN) is preparing to provide a change of shift report when an oncoming nurse arrives, appearing intoxicated, and who describes to another colleague about drinking all afternoon and almost forgetting to come to work. Which action should the PN take first?

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

The practical nurse (PN) has been regularly assigned the care of an older adult client who resides in a long term care facility. When the client is told that they have a terminal illness, which action is best for the PN to take?

While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?