The nurse is caring for a client who is at high risk for development of pressure injury.
The client is able to move independently, but has been placed on bedrest. The client has experienced two episodes of urinary incontinence. Which intervention(s) should the nurse include in the care plan? (SELECT ALL THAT APPLY)

Instruct client to shift their weight at least every 15 minutes

Keep head of bed raised at 45 degrees at all times

Massage over bony prominences every hour while awake

Apply moisture barrier cream to perineal skin

Consult with the wound care nurse about use of a specialty mattress

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale: Instructing the client to shift their weight at least every 15 minutes helps prevent pressure injuries.

Choice B rationale: Keeping the head of the bed raised at 45 degrees at all times is not a typical practice for preventing pressure injuries.

Choice C rationale: Massaging over bony prominences every hour while awake may not be recommended, as this can cause friction and shear, contributing to skin breakdown. Choice D rationale: Applying moisture barrier cream to perineal skin helps protect against skin breakdown from urinary incontinence.

Choice E rationale: Consulting with the wound care nurse about the use of a specialty mattress can provide additional support and help prevent pressure injuries.

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Correct Answer is B

Explanation

Choice A rationale: Propranolol 10 mg PO twice a day would typically be given with a more extended interval between doses, not at 10:00 AM, 2:00 PM, and 6:00 PM.
Choice B rationale: Diazepam 5 mg PO three times a day would align with the specified dosing schedule of 10:00 AM, 2:00 PM, and 6:00 PM.
Choice C rationale: Cephalexin 500 mg PO q4 hours would require more frequent dosing than the specified schedule.
Choice D rationale: Morphine Sulfate 10 mg IM q4 hours prn pain is ordered every 4 hours, not at the specified times of 10:00 AM, 2:00 PM, and 6:00 PM.

A. RLQ B. RUQ C. LUQ D. LLQ

Correct Answer is A

Explanation

Choice A rationale: RLQ (Right Lower Quadrant) is the correct abbreviation for the location of the appendix, which is typically found in the right lower quadrant of the abdomen.

Choice B rationale: RUQ (Right Upper Quadrant) is not the location of the appendix.

Choice C rationale: LUQ (Left Upper Quadrant) is not the location of the appendix.

Choice D rationale: LLQ (Left Lower Quadrant) is not the location of the appendix.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is transcribing a medication order and schedules dosing for 10:00 AM, 2:00 PM and 6:00 PM. Which medication order is consistent with this schedule?

Correct Answer is B

Explanation

A client is admitted to the hospital with a diagnosis of R/O appendicitis. Which abbreviation would describe the location of a client's appendix?

Correct Answer is A

Explanation

The nurse receives the following order: "Ferrous sulfate 325 mg four times a day PO. Give on empty stomach." Even before researching, the nurse guesses that this is because the medication:

A client is diagnosed with chronic constipation. The nurse is given an order by the physician to administer a glycerin suppository. What abbreviation will be written in the physician's order for the administration route for the suppository?

A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states, "I can't catch my breath." Which abbreviation would be used to document this presentation?

In order to minimize discomfort when giving an injection to a client, the nurse should:

The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:

The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

A nurse is caring for a client who has a diagnosis of alcohol withdrawal. Which serum laboratory value validates the client's admitting diagnosis? A serum: