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 D

Explanation

A. Transporting the client without protective equipment would not comply with droplet precaution protocols and could pose a risk of infection to others.
B. Placing goggles over the eyeglasses is not necessary if a surgical mask can be properly fitted, as the mask itself provides the needed protection for droplet precautions.
C. A fitted respirator-style mask is typically not required for droplet precautions; a surgical mask is sufficient.
D. Securing a surgical face mask over the bridge of the client's nose just below the eyeglasses ensures that the mask is properly fitted, providing adequate protection while allowing the client to wear their eyeglasses comfortably. This approach adheres to droplet precaution protocols.

A. Determine if the expected outcomes were realistic. B. Review related professional standards of care. C. Obtain current client data to compare with expected outcomes. D. Modify the nursing interventions to achieve the client's goals.

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.

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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 nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?

Correct Answer is D

Explanation

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

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