An older client with pernicious anemia uses hot packs to loosen psoriatic plaques. The practical nurse (PN) who assists with the care twice weekly should refer which finding to the home health care charge nurse?
Brown spots on hands and arms.
Areas of decreased pigmentation.
Erythema and edematous areas.
Yellow-white scales on the skin.
The Correct Answer is C
A. Brown spots on hands and arms: These are common age-related changes (lentigines) and are not an urgent concern related to hot pack use or psoriatic care.
B. Areas of decreased pigmentation: Hypopigmentation can occur in psoriasis or with chronic skin changes, but it is not typically a sign of acute injury or complication from heat therapy.
C. Erythema and edematous areas: Redness and swelling indicate possible skin irritation or burns from hot packs. These findings require prompt referral to the charge nurse for assessment and intervention to prevent further injury or infection.
D. Yellow-white scales on the skin: These are characteristic of psoriatic plaques and are expected findings. They do not signal a complication from the heat therapy and do not require immediate referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiate toileting schedule: Because the client is anuric and does not produce urine, a toileting schedule is unnecessary and would not contribute to their care.
B. Provide perineal skin barrier cream: While skin care is important, the absence of urine output reduces the risk of urinary-related skin breakdown, so this is not a priority intervention.
C. Encourage intake of high potassium foods: Clients with anuria and CKD are at high risk for hyperkalemia. Encouraging high potassium intake could be dangerous and is contraindicated.
D. Monitor for signs of anemia: Chronic kidney disease often leads to reduced erythropoietin production, causing anemia. Monitoring for fatigue, pallor, and lab values is essential for timely intervention and maintaining client safety.
Correct Answer is ["A","B","D"]
Explanation
A. Provide sips of water to a client who is 4 hours postoperative: Offering fluids is within the UAP’s scope of practice as a non-invasive, routine activity. It does not require clinical judgment or direct supervision by the PN.
B. Assist a client to the car for discharge home: Assisting with ambulation or mobility for discharge is appropriate for a UAP. It involves physical support and safety measures but does not require clinical decision-making or supervision during the task.
C. Administer oral medications to a client with paraplegia: Medication administration requires assessment, knowledge of indications, contraindications, and monitoring for adverse effects, which is beyond the UAP’s scope. The PN must perform this task.
D. Collect a voided specimen before client is catheterized: Collecting a non-invasive urine specimen is appropriate for the UAP. It involves standard precautions and proper labeling but does not require clinical judgment or supervision.
E. Insert a foley catheter in a frail elderly client: Catheter insertion is an invasive procedure requiring sterile technique and assessment skills. This task must be performed by licensed nursing personnel and cannot be delegated to a UAP.
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