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. Place the client in an orthopneic position: Positioning the client is important for optimal lung expansion a nd procedural access, but it is typically done immediately before the procedure. Preparing equipment beforehand ensures the procedure can start efficiently and safely.
B. Cleanse the site and cover with a sterile towel: Skin preparation is a critical step for infection prevention, but it is performed by the healthcare provider or under their guidance just prior to the thoracentesis, not as an initial preparation by the PN.
C. Keep the client NPO and encourage to void: Fasting is not generally required for thoracentesis, and voiding may be encouraged for comfort, but these steps are secondary to ensuring all necessary equipment is ready for a safe procedure.
D. Gather the procedure tray and equipment: Preparing all required equipment and supplies ensures the procedure can be performed promptly and safely once the provider arrives. This is the most important preparatory action the PN can take to facilitate an efficient and safe thoracentesis.
Correct Answer is A
Explanation
A. Insert the catheter into the tracheostomy: The PN must gently and quickly insert the suction catheter without applying suction (to prevent damage to the mucosa and oxygen depletion) until resistance is met or the client coughs. This places the catheter in the correct position for suctioning secretions.
B. Use the thumb to apply intermittent suction: Applying suction is the step that occurs after the catheter has been fully inserted to the desired depth and is being withdrawn. Applying suction during insertion can cause trauma and hypoxia.
C. Explain the need for the client to swallow: The client with a tracheostomy doesn't swallow through the tracheostomy tube. While the PN should explain the procedure and encourage deep breaths before starting, this is not a correct or necessary instruction for the immediate next step of insertion.
D. Stop the procedure to obtain new supplies: The image doesn't show any breach in sterile technique or a lack of supplies that would necessitate stopping the procedure. The PN appears ready to proceed.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.