The nurse is caring for a client with full hearing loss. What should the nurse recommend for the home environment?

Have the client move in with a family member or close friend.

Encourage the client to get a roommate.

Increase the sound on all alarms.

Install flashing lights for alarms.

Answer and Explanation

The Correct Answer is D

A: Having the client move in with a family member or close friend can provide emotional support and assistance with daily activities. However, it does not specifically address the safety needs related to hearing loss. While this option can be beneficial, it is not the most direct solution for ensuring the client’s safety in their home environment.

B: Encouraging the client to get a roommate can also provide companionship and assistance. However, like option A, it does not directly address the specific safety concerns associated with hearing loss. The presence of a roommate might help in emergencies, but it is not a guaranteed solution for all safety issues.

C: Increasing the sound on all alarms might seem like a logical step, but it is not effective for someone with full hearing loss. This approach does not ensure that the client will be alerted to emergencies, as they may not hear the alarms regardless of the volume.

D: Installing flashing lights for alarms is the most effective recommendation for a client with full hearing loss. Visual alarms can alert the client to emergencies such as fires or intruders, ensuring their safety. This solution directly addresses the client’s inability to hear auditory alarms and provides a reliable method for emergency alerts.

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Correct Answer is C

Explanation

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

A. Intact skin with localized erythema. B. Full-thickness skin loss with visible adipose tissue. C. Partial-thickness skin loss with red tissue in wound bed. D. Full-thickness skin loss with visible bone.

Correct Answer is C

Explanation

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

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The nurse is caring for a client with full hearing loss. What should the nurse recommend for the home environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a healing Stage II pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?

Correct Answer is C

Explanation

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

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The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse’s action?

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client’s infection?

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