Patient Data

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices

Pressure injury: The client has non-blanchable redness on the coccyx with intact skin, indicating a Stage 1 pressure injury. Risk factors include limited mobility, obesity, neuropathy, incontinence, and poor nutrition, making prevention and early intervention critical.
Offload coccyx and other bony prominences: Relieving pressure is essential to prevent further tissue damage. This includes repositioning the client at least every two hours and using support surfaces such as foam wedges or specialized mattresses.
Cleanse and dress wound: Maintaining skin integrity and hygiene prevents infection. Gentle cleansing and application of a protective dressing reduces friction, moisture, and bacterial colonization on the affected area.
Wound status: Monitoring wound characteristics such as size, color, and drainage ensures that interventions are effective and allows early detection of deterioration or infection.
Documentation of skin prevention measures: Recording interventions, repositioning schedules, and skin assessments helps evaluate adherence to the prevention plan and communicates continuity of care among the healthcare team.

Rationale for Incorrect Choices

Elder abuse: While vulnerability exists, there is no evidence of physical trauma or neglect; the findings are consistent with pressure-related injury from immobility rather than external harm.
Altered nutrition: Although the client has suboptimal intake and weight concerns, nutrition alone does not explain the presence of localized non-blanchable redness; this is primarily a pressure injury issue.
Bowel obstruction: The client reports occasional incontinence but no vomiting, abdominal distension, or absent bowel sounds. These signs do not suggest obstruction, making this an unlikely acute concern.
Administer an enema: The client’s incontinence and skin findings do not indicate constipation or impaction requiring immediate enemas. This action would not address the pressure injury.
Contact adult protective services: There is no indication of neglect or abuse at home; intervention should focus on skin care and prevention rather than protective services.
Immediately begin a bowel training program: Bowel management is important for incontinence but is not the immediate priority. The client’s acute skin compromise requires urgent offloading and wound care first.
Vital signs: While monitoring vital signs is standard, they do not directly reflect the progression or improvement of the pressure injury, so this is secondary for assessing this condition.
Family dynamics: The client lives alone and the issue is primarily related to physical risk factors. Monitoring family interactions does not provide immediate information about the wound or skin integrity.
Incontinence episodes: Tracking incontinence is relevant for prevention planning but does not assess the current injury or healing status, making it less critical than wound monitoring and documentation.

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 D

Explanation

A. Leave the door to the client's room open slightly: Leaving the door open can help the client feel less isolated and allow staff to observe them more easily. However, this does not directly promote relaxation or address the client’s difficulty sleeping.

B. Apply wrist restraints to prevent wandering: Using restraints is a last resort and is inappropriate as an initial intervention. Less restrictive, nonpharmacological interventions should always be attempted first.

C. Administer a PRN sedative prescription: Administering sedatives should only occur after nonpharmacological measures have failed, as older adults are at higher risk of falls, confusion, and adverse drug effects. Promoting comfort and relaxation naturally is preferred before resorting to medications.

D. Provide a back rub at bedtime: Providing a gentle back rub is the most appropriate first intervention because it promotes relaxation, comfort, and improved circulation. This nonpharmacological approach can help the client fall asleep naturally and reduce restlessness without introducing additional risks.

A. Advance the catheter before inflating balloon. B. Use a swab to wipe the meatus in back-and-forth motions. C. Clean the urinary meatus before retracting the foreskin. D. Position the sterile field even with the nurse's hips.

Correct Answer is A

Explanation

A. Advance the catheter before inflating balloon: The catheter must be fully inserted into the bladder before inflating the balloon to prevent trauma to the urethra and ensure proper placement. Inflating the balloon prematurely can cause pain, injury, and improper function of the catheter.

B. Use a swab to wipe the meatus in back-and-forth motions: Cleaning should be performed in a circular motion from the meatus outward to reduce the risk of introducing bacteria into the urethra. Back-and-forth motions can spread contaminants toward the urinary opening.

C. Clean the urinary meatus before retracting the foreskin: The foreskin should be retracted first to fully expose the glans. Cleaning the meatus without retraction can result in incomplete hygiene and increase infection risk.

D. Position the sterile field even with the nurse's hips: Sterile field placement should be above waist level and in a comfortable position for maintaining sterility, but aligning it with the hips does not specifically ensure safe catheter insertion.

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

Patient Data

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is D

Explanation

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Correct Answer is A

Explanation

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow- up action should the nurse take first?

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

The healthcare provider prescribes streptomycin 200 mg intramusculary every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL". How many milliliters should the nurse administer? (Enter numerical value only. (If rounding is required, round to the nearest tenth.)

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?