The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?
Instruct the unlicensed assistive personnel to frequently offer oral fluids.
Prepare to implement a pressure redistribution mattress.
Explain to the client that the wound needs debridement.
Obtain hemoglobin of the side to check for anemia and sensitivity.
The Correct Answer is B
Pressure redistribution is an important part of preventing and treating pressure sores1.
Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.
Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.
Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.
This position allows the medication to flow into the ear canal and reach the site of infection.
Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.
Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.
Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.
Correct Answer is B
Explanation
The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.
According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.
Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.
Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.
Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.
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