Which of the following patients are at highest risk for developing a skin injury caused by shearing?

A patient who is lying on wrinkled sheets.

A patient who is pulled up in the bed by the nurse

A patient who is frequently incontinent.

A patient who is noted to have slough tissue

Answer and Explanation

The Correct Answer is B

A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.

B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.

C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.

D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.

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Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

A. The relationship occurs spontaneously. B. It is based on the needs of the nurse. C. The nurse and client will have a social relationship. D. The nurse is accountable for the outcome.

Correct Answer is D

Explanation

A. The relationship occurs spontaneously: Therapeutic relationships are intentional and structured, unlike spontaneous social interactions.

B. It is based on the needs of the nurse: The relationship is centered on the needs of the client, not the nurse.

C. The nurse and client will have a social relationship: A therapeutic nurse-client relationship is professional, not social. It focuses on supporting the client’s well-being.

D. The nurse is accountable for the outcome: The nurse is responsible for maintaining professional boundaries and ensuring that the relationship supports the client’s health goals.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

Which of the following patients are at highest risk for developing a skin injury caused by shearing?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?

Correct Answer is D

Explanation

A patient is on isolation for neutropenia. What statement made by the patient requires additional education from the nurse?

A student nurse is assigned a patient to provide care for throughout the day. Which of the following actions would violate client confidentiality?

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Which of the following clients should avoid the use of cold therapy?

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Order: Metoprolol Tartrate 25 mg PO each morning Available: Metoprolol Tartrate 50 mg tablets How many tablets will you administer per dose?

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