The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?

Instruct the unlicensed assistive personnel to frequently offer oral fluids.

Prepare to implement a pressure redistribution mattress.

Explain to the client that the wound needs debridement.

Obtain hemoglobin of the side to check for anemia and sensitivity.

Answer and Explanation

The Correct Answer is B

Pressure redistribution is an important part of preventing and treating pressure sores1.

Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.

Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.

Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure

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Correct Answer is C

Explanation

The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.

Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.

Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.

Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.

A. Change coccyx dressing after performing routine care. B. Change coccyx dressing before performing routine care. C. Restate the vital importance of performing hand hygiene. D. Perform coccyx dressing change in the nursing station.

Correct Answer is C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

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The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores. What actions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative client has been prescribed three different analgesics for different levels of pain. What is the most important intervention the nurse should take when administering these medications to the client?

Correct Answer is C

Explanation

A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections. Which intervention is most appropriate to prevent the spread of MRSA to others?

Correct Answer is C

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?

The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?