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.

Answer and Explanation

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

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Correct Answer is B

Explanation

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

A. Ask the UAP to offer back rubs to the client. B. Reassess the client and the level of pain. C. Encourage the client to focus on taking deep breaths. D. Tell the client the medication needs more time to work.

Correct Answer is B

Explanation

The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.

Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.

Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.

Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

Correct Answer is B

Explanation

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

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The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?

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?

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?