A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

decubitus ulcers.

foot drop.

pooling of blood.

blood pressure changes.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.

A. purulent B. serous C. sanguineous D. serosanguineous

Correct Answer is D

Explanation

Choice A rationale: Purulent drainage is thick and opaque, often indicating infection.
Choice B rationale: Serous drainage is thin and watery, typically clear or slightly yellow.
Choice C rationale: Sanguineous drainage is bright red and indicates fresh bleeding.
Choice D rationale: Serosanguineous drainage is thin and pale pink-yellow, representing a mixture of serous and sanguineous components.

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A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

Correct Answer is D

Explanation

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

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

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?