A nurse is caring for a client in a medical-surgical unit

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

Weight (B): Monitor weight to assess for fluid retention and overload.
Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. "Wash with plain soap and water." While cleanliness is important, plain soap can be drying and irritating. Gentle cleansing is better, using products that do not strip the skin of natural oils.

B. "Sit in the sun for 10 minutes per day." Sun exposure can exacerbate radiation dermatitis and should be avoided. The skin needs protection from additional UV damage.

C. "Apply moist heat." Moist heat can further irritate already sensitive skin and is not recommended for treating radiation-induced skin reactions.

D. "Apply hydrating lotions." Hydrating lotions help to soothe and moisturize the skin, promoting healing and alleviating dryness and scaling caused by radiation treatment. Use products specifically recommended for sensitive or radiated skin.

A. instruct the client to dig their heels into the bed to push themselves upwards. B. Assist the client with a trapeze to raise their body while staff assists with repositioning C. Have two to three staff members pull the client up in bed when needed. D. Elevate the head of the bed 90° for bedridden clients.

Correct Answer is B

Explanation

A. Instruct the client to dig their heels into the bed to push themselves upwards: This increases friction on the heels, which can lead to skin breakdown.

B. Assist the client with a trapeze to raise their body while staff assists with repositioning. Using a trapeze allows the client to lift themselves slightly off the bed, reducing the friction and shear forces that can cause skin injuries during repositioning.

C. Have two to three staff members pull the client up in bed when needed: This increases the risk of friction injuries, especially if the client is not lifted properly.

D. Elevate the head of the bed 90° for bedridden clients: High elevation of the bed can increase the risk of shear injuries due to sliding down in bed.

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Naxlex Comprehensive Predictor Exams

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Correct Answer is D

Explanation

A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

Correct Answer is B

Explanation

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