A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?

Explain alternatives to the procedure to the client.

Discuss the risks of the procedure with the client.

Confirm that the client is competent to sign for the procedure.

Inform the client about what will occur during the procedure.

Answer and Explanation

The Correct Answer is C

A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.

B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.

C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.

D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.

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Correct Answer is A

Explanation

A.Adequate protein intake is essential for skin repair and maintaining skin integrity. Protein helps in the healing process, supports the immune system, and strengthens the skin, making it more resistant to breakdown. This is a crucial intervention for preventing pressure ulcers and promoting overall skin health in older adults.

B.Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

C.Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

D.While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

A. Abrasion B. Contusion C. Laceration D. Puncture

Correct Answer is C

Explanation

A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.

B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.

C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.

D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.

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A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?

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 client's skin integrity?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

Correct Answer is C

Explanation

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