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. Acupuncture is considered higher risk and usually requires specialized training.
B. Acupressure is also higher risk and requires specific knowledge and skill.
C. Music, relaxation, and touch are considered low-risk therapies that can be safely used by nurses to enhance patient comfort and well-being.
D. Hypnotherapy is a more specialized therapy that may require additional training.

A. Dilute each medication with 10 mL of tap water. B. Maintain the head of the bed in a flat position for 30 min following medication administration. C. Mix the three medications together prior to administering. D. Flush the NG feeding tube with 30 ml of water immediately following medication administration

Correct Answer is D

Explanation

A. Medications should be diluted as per pharmacy recommendations, not arbitrarily with 10 mL of tap water.
B. The head of the bed should be elevated to at least 30-45 degrees during and after feeding to prevent aspiration.
C. Medications should not be mixed together to avoid interactions unless recommended by the pharmacy.
D. Flushing the NG feeding tube with 30 mL of water immediately following medication administration ensures that the medication has cleared the tube and prevents clogging.

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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

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Naxlex Comprehensive Predictor Exams

Which of the following are examples of low-risk complementary and alternative therapies that nurses can use with their clients?

Correct Answer is C

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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 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

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