A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Implementation.

Planning.

Evaluation.

Assessment.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.

Choice B rationale:

Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.

Choice C rationale:

Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.

Choice D rationale:

Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.

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Correct Answer is A

Explanation

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

A. Femoral. B. Popliteal. C. Brachial. D. Carotid.

Correct Answer is B

Explanation

Choice B rationale:

The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.

Choice A rationale:

Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.

Choice C rationale:

Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.

Choice D rationale:

Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.

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A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Correct Answer is B

Explanation

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