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 C

Explanation

Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.

Choice A is not the correct answer because reading a book about how to sleep better is not a contributing factor to fatigue and difficulty sleeping.

Choice B is not the correct answer because exercising in the morning and afternoon can actually help improve sleep.

Choice D is not the correct answer because sleeping between 10 PM and 9 AM each night is a normal sleep schedule and should not contribute to fatigue and difficulty sleeping.

A. Demonstrate the skill speaking slowly and using simple terms. B. Reassure the client that the skill is not difficult to learn. C. Reduce the stimuli in the area before continuing the teaching. D. Provide the client with step-by-step written instruction.

Correct Answer is C

Explanation

Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.

Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.

Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.

Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.

Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.

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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

A client presents to the doctor's office with a report of fatigue and difficulty sleeping. Which information should the nurse recognize as a potential contributing factor?

Correct Answer is C

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is C

Explanation

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

A client receives a prescription for a one-time dose of metronidazole 2 grams by mouth. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numerical value only).

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

The nurse is caring for a patient one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

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 observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?