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 ["1"]

Explanation

The nurse should instruct the client to take 1 tablespoon within each dose.

Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled “Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL”, the client should take 15 mL of the suspension per dose.

Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.

A. Providing physical demonstration. B. Using simulation activities. C. Incorporating verbal analogies. D. Offering positive reinforcement.

Correct Answer is B

Explanation

Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .

Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .

Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .

Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .

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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 receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

Correct Answer is ["1"]

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

Correct Answer is B

Explanation

An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?

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?

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

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?

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?

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?