Patient Data

Exhibits

Review was done of H and P, nurses' notes, and orders.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Pressure sores are divided into different stages:

Stage 1= Intact skin with non-blanchable redness over a localized area

Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base

Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed

Stage 4- Full thickness wound with exposed tendons, muscle and bone

Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue

The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.

Nutritional status determines the risk of developing pressure injury and the chances of wound healing.

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Free Nursing Study Resources

Correct Answer is D

Explanation

D. This action demonstrates understanding of the importance of donning gloves when entering a client's room to prevent the transmission of microorganisms between clients and to maintain infection control practices. It is essential for UAP to don gloves before providing care to clients to reduce the risk of contamination and infection transmission.
A. Sterile gloves are typically not necessary for routine handling of body fluids unless performing a sterile procedure. Non-sterile gloves are sufficient for most tasks involving body fluids.
B. Sterile gloves are typically not necessary for routine care of clients with HIV unless performing a sterile procedure.
C. While it's convenient to have gloves readily available, keeping them in a pocket without proper storage or protection may compromise their sterility and effectiveness.

A. 1400 B. 1200 C. 1800 D. 1600 E. 0800 F. 2000 G. 1500

Correct Answer is ["B","D","E","F","G"]

Explanation

The order is vital signs to be taken every 4 hours

Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Correct Answer is D

Explanation

Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

Correct Answer is ["B","D","E","F","G"]

Explanation

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate. the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

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