The staff nurses have just received an inservice presentation about pressure Injury risk reduction in their clients. Which points should have been Included? (SELECT ALL THAT APPLY) Assess client's:

usual nutritional intake.

degree of physical activity.

skin exposure to moisture.

food and drug allergies.

ability to respond to pressure-related discomfort.

Answer and Explanation

Correct Answer : A,B,C,E

A. Assessing usual nutritional intake helps identify potential risk factors for poor wound healing and pressure injury development.

B. Assessing the degree of physical activity helps determine the client's mobility level and risk for pressure injuries.

C. Assessing skin exposure to moisture helps identify potential areas of skin breakdown and pressure injury development.

D. While important, assessing food and drug allergies is not directly related to pressure injury risk reduction.

E. Assessing the client's ability to respond to pressure-related discomfort helps identify clients who may be at increased risk for pressure injuries due to decreased mobility or sensory deficits.

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

Explanation

A. Room number is not typically considered one of the "rights" associated with medication administration.

B. Prescriber is not typically considered one of the "rights" associated with medication administration.

C. Documentation: documenting the medication administration is essential for accountability and continuity of care.

D. Dose: verifying the correct dosage is another crucial "right" to prevent medication errors.

E. Assessment: assessing the client's condition and suitability for the medication is also a vital aspect of medication administration.

A. Apply a sterile normal saline dressing B. Use sterile gloves to replace the protruding parts C. Administer IV antibiotics STAT D. Place the client in reverse Trendelenburg position

Correct Answer is A

Explanation

A. if a client's abdominal wound has eviscerated, the first intervention should be to apply a sterile normal saline dressing to the area and then seek immediate medical assistance.

B. Using sterile gloves to replace the protruding parts is not recommended since it can result in further damage of the organs.

C. Administering IV antibiotics may be indicated later but is not the first priority.

D. Placing the client in reverse Trendelenburg position is not the first priority and may not be appropriate for managing evisceration.

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The staff nurses have just received an inservice presentation about pressure Injury risk reduction in their clients. Which points should have been Included? (SELECT ALL THAT APPLY) Assess client's:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes ten "rights" associated with giving medications to clients. Which are Included in this group? (SELECT ALL THAT APPLY)

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

Explanation

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

When administering oxygen via a wall-outlet system, the nursing intervention that would be necessary for a 3 L/min flow, as opposed to a 1 L/min flow, would be:

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