When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Apply a warm compress to the sacral area.

Wash the area with soap and water.

Reassess and turn the client in 30 minutes.

Massage the reddened area with lotion.

Answer and Explanation

The Correct Answer is C

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

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Correct Answer is B

Explanation

A. The use of "2.0 mg" is incorrect because trailing zeros can lead to dosage errors. The correct documentation should avoid trailing zeros to prevent misinterpretation.
B. "Morphine 2 mg IV every 4 hr PRN for severe pain" is the correct format. It uses the full name of the drug, avoids abbreviations that could be confused, and follows best practices for documenting as-needed (PRN) medications.
C. Using "MS" instead of "morphine" is not recommended because "MS" can be confused with magnesium sulfate or other medications. The full drug name should always be used.
D. Similar to option A, the use of "2.0 mg" includes a trailing zero, which should be avoided to reduce the risk of errors in medication administration.

A. Ask questions in a vague, nonspecific format. B. Get the most difficult questions over with first. C. Share personal values to put the client at ease. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

A. Asking vague or nonspecific questions can lead to unclear answers, which may hinder the assessment process. Specific and direct questions are more effective.
B. Starting with the most difficult questions may make the client uncomfortable and less willing to share information. It's better to build rapport first.
C. Sharing personal values is not appropriate as it may influence or pressure the client. The focus should be on the client’s values and experiences.
D. Beginning with questions that are less sensitive helps to build rapport and trust with the client, making them more comfortable discussing more sensitive topics later in the conversation.

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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?

Correct Answer is B

Explanation

Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?

Correct Answer is D

Explanation

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