A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Receiving bronchodilator medication

Weight loss of 2.8 kg (6.2 b)

Hemoglobin 17 g/dl (12 to 16 g/dL)

Wearing an oxygen device

Answer and Explanation

The Correct Answer is B

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

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Correct Answer is C

Explanation

C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.

A. Use an elevated toilet seat. B. Log roll the client onto the operative side. C. Keep client's affected heel on the bed. D. Perform internal and external rotation exercises of hip.

Correct Answer is A

Explanation

A. Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.

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A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

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A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?