While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Avoid friction when sliding up in bed.

Offer supplemental nutritional snacks.

Change bed pads to keep skin clean and dry.

Change position frequently from right to left.

Answer and Explanation

The Correct Answer is D

A.   While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B.   Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C.   While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D.   The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

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Correct Answer is B

Explanation

A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.

A. Voiding after intercourse to reduce infection. B. Need for scheduling annual well woman exams. C. The importance of using vaginal lubricants. D. Intercourse positions that can help prevent tears.

Correct Answer is C

Explanation

A. While voiding after intercourse can help reduce the risk of urinary tract infections (UTIs), it is not directly related to preventing vaginal tears. This practice is more relevant for preventing infections rather than addressing the issue of tissue trauma or dryness that may lead to tearing.
B. Regular well-woman exams are important for overall gynecological health and early detection of potential issues, but they do not directly address the immediate concern of preventing vaginal tears during intercourse.
C. Vaginal dryness is a common issue in older women, often due to decreased estrogen levels. Dryness can make vaginal tissues more susceptible to tearing during intercourse. Using vaginal lubricants can help reduce friction and prevent tears, making this the most relevant and practical advice for the client in this situation.
D. While certain positions may be more comfortable and could potentially reduce the risk of tearing, this advice is secondary to addressing the fundamental issue of vaginal dryness. Focusing on lubrication provides a more direct and effective approach to preventing tears.

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While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Correct Answer is C

Explanation

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?