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 A
Explanation
Inject in abdominal area at least 2 inches from the umbilicus.
When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh.
Your tummy is usually best as the injection site and it is important that you change the site each time 1.
The heparin needs to go into the fat layer under the skin 2.
Choice B is incorrect because injections should not be rotated between the abdomen and gluteal areas.
Choice C is incorrect because massaging the injection site is not recommended.
Choice D is incorrect because air bubbles in a pre-filled syringe should not be expelled prior to injection 2.
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.
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