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. Tennis shoes with velcro. B. Rubber-soled slippers. C. Slip-on rubber shower shoes. D. Leather-soled loafers.

Correct Answer is A

Explanation

A. Tennis shoes with velcro are recommended because they provide good support, traction, and stability, which are crucial for a client with residual weakness after a stroke. The velcro allows for easy adjustment and ensures the shoes are secure, reducing the risk of tripping or falling.
B. Rubber-soled slippers, while comfortable, may not offer the necessary support or secure fit needed for safe ambulation.
C. Slip-on rubber shower shoes are not suitable for ambulation outside of the shower area due to their lack of support and potential to slip off.
D. Leather-soled loafers can be slippery and do not provide the traction needed for safe walking, especially on smooth surfaces.

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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

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

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is A

Explanation

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