Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Applies powder after drying the skin.

Has been NPO for four days.

Bathes twice a week.

Has hypertension.

Answer and Explanation

The Correct Answer is B

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

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Correct Answer is A

Explanation

This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.

Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.

Giving rescue breaths to a client who has a pulse may cause harm.

Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.

Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.

Chest compressions may cause harm to a client who has a pulse.

A. “Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.”. B. “I will urinate less when taking Clozaril, and that is normal.”. C. “I will use the Clozaril as needed for delusions and hallucinations.”. D. “Clozaril is now available over-the-counter and in a generic form.”.

Correct Answer is A

Explanation

“Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.” This indicates that the client understands that Clozaril (clozapine) is an antipsychotic medication that can affect the immune system and cause a serious blood disorder called agranulocytosis. The client needs to have regular blood tests to monitor the white blood cell count and prevent infections.

Choice B is wrong because Clozaril can cause urinary retention, not decreased urination. The client should be advised to report any difficulty or pain when urinating.

Choice C is wrong because Clozaril is not a PRN medication. It should be taken regularly as prescribed by the doctor to maintain a therapeutic level and prevent relapse of psychotic symptoms.

Choice D is wrong because Clozaril is not available over the counter or in a generic form. It is a controlled substance that requires a special program and a certified pharmacy to dispense it.

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Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?

Correct Answer is A

Explanation

Which response by the client indicates that medication instruction by the RN has been effective?

Correct Answer is A

Explanation

A client is to receive one liter of normal saline intravenously over six hours. The tubing delivers 15 drops per milliliter. How many drops per minute should a nurse regulate the infusion to deliver?

A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Which task could a nurse delegate to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit?

The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

A client has been newly diagnosed with hypothyroidism. What symptoms or signs would be expected with this diagnosis? Select all that apply.

The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

A client with severe bronchial pneumonia has been receiving oxygen, respiratory treatments, antibiotics, and intravenous fluids. Which arterial blood gas result would indicate that the treatment has been effective?