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 C

Explanation

A. Determining if the expected outcomes were realistic is important but comes after comparing the actual client data with the expected outcomes. If the outcomes were unrealistic, it would be identified during this comparison.
B. Reviewing professional standards of care is important for ensuring that care meets quality standards but is not the immediate next step after reviewing the expected outcomes.
C. Obtaining current client data to compare with expected outcomes is the next step to assess whether the client’s condition has improved, worsened, or remained the same. This comparison is crucial for evaluating the effectiveness of the nursing care.
D. Modifying nursing interventions should be done based on the evaluation of client data and outcomes. It is a subsequent step after assessing whether the outcomes have been met.

A. Use firm pressure to pass the tube through the glottis. B. Have the client tilt head backward to open the passage. C. Give the client a few sips of water to drink. D. Remove the tube and attempt reinsertion.

Correct Answer is C

Explanation

A. Using firm pressure to pass the tube through the glottis can cause discomfort and potentially damage the client's airway. It is important to proceed with caution and avoid causing harm.
B. Tilting the head backward can actually make the insertion more difficult and increase the risk of gagging or aspiration. Proper head positioning typically involves slight flexion.
C. Giving the client sips of water is not recommended during NGT insertion as it can exacerbate gagging and increase the risk of aspiration.
D. Removing the tube and attempting reinsertion is the appropriate action if the client begins to gag. It allows the nurse to reposition the tube and attempt insertion more gently, ensuring the tube is correctly placed without causing undue discomfort or harm.

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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?

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Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is C

Explanation

The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

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