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 B

Explanation

A. Leaning against a bedside table does not provide adequate support or comfort for coughing.
B. Splinting the abdomen with a pillow supports the incision site and reduces pain, making it easier for the patient to cough effectively.
C. Supporting the patient's back is helpful but not as effective as abdominal splinting for reducing pain during coughing.
D. Offering an antitussive is not appropriate as it suppresses coughing, which is needed to clear secretions postoperatively.

A. Inform the client that this drug combination is most effective if the ginkgo biloba is taken twice daily. B. Inform the client that memory problems following valve replacement surgery are common, but temporary. C. Instruct the client that ginkgo biloba interacts with anticoagulant drugs and then check for bruising or bleeding. D. Instruct the client to keep a record of episodes of forgetfulness or memory disturbances to monitor effectiveness.

Correct Answer is C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

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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

What technique will the nurse implement to assist the postoperative patient to cough?

Correct Answer is B

Explanation

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Correct Answer is C

Explanation

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

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

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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 caring for a client who has a large lower leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?