A nurse performing a right eye irrigation will position the patient:

Supine with the head tilted toward the right eye.

Upright with the head tilted toward the left eye.

Upright with the head hyperextended.

Supine with the head hyperextended.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

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Correct Answer is B

Explanation

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

A. A client who is unresponsive to verbal commands and changes position occasionally. B. A client who is alert and responsive and eats 25% of each meal. C. A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

Correct Answer is A

Explanation

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

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A nurse performing a right eye irrigation will position the patient:

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Naxlex Comprehensive Predictor Exams

The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

Correct Answer is B

Explanation

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is A

Explanation

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

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