The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Middle-aged man experiencing the acute phase of myocardial infarction (MI)

Older adult with a history of dementia admitted for dehydration

Young adult in the rehabilitative phase after arthroscopic surgery

Middle-aged woman just diagnosed with terminal lung cancer

Answer and Explanation

The Correct Answer is A

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I will wear gloves and a gown when bathing a client who has open skin lesions.": This statement indicates an understanding of the appropriate use of personal protective equipment (PPE) in a situation where there is a risk of exposure to blood or bodily fluids. Wearing gloves and a gown helps protect the AP from potential pathogens present in the client's open skin lesions.

B. "I will wear gloves when measuring a client's blood pressure.": While it may be appropriate to wear gloves for certain procedures, it is not universally required to wear gloves when measuring blood pressure unless there are specific concerns about contamination or exposure to body fluids. This statement does not demonstrate a clear understanding of when gloves are necessary.

C. "I will wear gloves whenever I am in contact with clients.": This statement suggests a lack of understanding of the appropriate use of gloves. Gloves should be used when there is a risk of contact with blood, body fluids, or open wounds, but they are not necessary for all interactions with clients, especially if there is no risk of contamination.

D. "I will wear gloves to minimize the number of times I have to wash my hands.": This statement indicates a misunderstanding of the primary purpose of gloves. Gloves are used to protect both the caregiver and the client from infection, and hand hygiene should still be performed before and after glove use. The focus should be on infection control rather than convenience.

A. Diarrhea B. Contractures of the extremities C. Polyuria D. Pressure ulcers E. Crackles in the lungs

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

Explanation

A. Diarrhea: Diarrhea is not a typical finding associated with immobility. In fact, immobility often leads to constipation due to decreased gastrointestinal motility. Factors such as diet and medication can influence bowel habits, but diarrhea is not a direct complication of immobility.

B. Contractures of the extremities: Contractures are a common complication of immobility. When a joint is not moved regularly, the muscles and tissues can shorten, leading to stiffness and loss of mobility in the affected area. This is especially common in patients who are bedridden or have limited range of motion.

C. Polyuria: Polyuria, or increased urine output, is not typically associated with immobility. Immobility can lead to decreased kidney function and fluid retention, potentially resulting in oliguria (decreased urine output) rather than polyuria.

D. Pressure ulcers: Pressure ulcers, also known as bedsores, are a significant risk for individuals with limited mobility. They develop due to prolonged pressure on the skin, particularly over bony prominences, leading to skin breakdown and tissue damage. Regular repositioning and skin care are essential to prevent this complication.

E. Crackles in the lungs: Crackles can be heard during auscultation in patients who are immobile. They may develop due to fluid accumulation in the lungs, atelectasis (collapse of lung tissue), or pneumonia, which are all more likely to occur in individuals with limited mobility. Immobility can impair respiratory function, leading to these complications.

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The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

Correct Answer is A

Explanation

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply)

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

Explanation

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?

When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?