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

When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.

This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.

Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.

Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.

Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.

A. Remind the UAP to locate the thermometer before gently inserting the ear. B. Demonstrate the correct technique for pulling the client's auricle up and back. C. Advise the UAP to hold the thermometer securely in place to obtain the measurement. D. Use positive reinforcement to affirm that the procedure being performed correctly.

Correct Answer is D

Explanation

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

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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

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?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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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?

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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?