A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

Provide the patient with a high-calorie, high-protein diet.

Change the patient's position every 2 hours, avoiding the supine position.

Change the patient's linen daily.

Record the size and appearance of the ulcer daily.

Answer and Explanation

The Correct Answer is B

A. While a high-calorie, high-protein diet is beneficial for wound healing, it is not the most critical factor in preventing further tissue damage.
B. Changing the patient's position every 2 hours is crucial to relieve pressure on the ulcer and prevent further tissue damage.
C. Changing the patient's linen daily is important for hygiene but does not directly prevent pressure ulcer progression.
D. Recording the size and appearance of the ulcer is important for monitoring, but preventing further damage through repositioning is more critical.

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Correct Answer is C

Explanation

A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.

A. "I watch television until I fall asleep at night." B. I have a small snack and take a bath before going to bed each day." C. "I don't take naps throughout the day." D. "I go to bed and get up routinely at the same time each day."

Correct Answer is A

Explanation

A. Watching television until falling asleep can interfere with the ability to fall asleep and stay asleep due to the stimulating effects of screen time and blue light.
B. Having a small snack and taking a bath before bed are good practices that can promote relaxation and help induce sleep.
C. Avoiding naps throughout the day can help improve nighttime sleep quality and maintain a consistent sleep schedule.
D. Going to bed and getting up at the same time each day helps regulate the body's internal clock and improve sleep quality.

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A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?

Correct Answer is C

Explanation

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an Indication that the client needs further teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

Which fluid or product to be infused requires a central venous access rather than a peripheral access?

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?

A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?

A client tells a nurse that she is considering using herbal supplements in addition to her prescription medications. What would be the nurse's best response?

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?