A 70-yr-old client popularity submit hip alternative is transferred to a rehabilitation facility. Which
scale must the realistic nurse (PN) pick out as the best device to expect the client's danger for
developing pores and skin breakdown?
A. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale - ANS-a. Braden Scale
The Braden Scale is made up of six subscales: sensory notion, moisture, activity, mobility,
nutrients, and friction and shear. A hospitalized person with a rating 16 or underneath or an
older grownup with a score of 18 or beneath is at an extended hazard for pores and skin
breakdown.
A customer involves the hospital and reports the presence of a painful lesion inside the genital
place; they defined it as a blister 2 days in advance that is now crusty. Which intervention ought
to the practical nurse (PN) put in force first?
A. Ask the client in the event that they have had unprotected intercourse.
B. Prepare the customer for a way of life and sensitivity check of the lesion.
C. Inform the purchaser this occurrence will must be mentioned to the public fitness department.
D. Prepare to manage penicillin intramuscularly into the dorsogluteal region. - ANS-a. Ask the
customer in the event that they have had unprotected sex.
Rationale:
These are typical signs and signs of herpes simplex virus 2 (HSV2), a sexually transmitted
disorder (STD), so the PN need to ask the client in the event that they had unprotected
intercourse and if the customer has exposed others to the disorder.
A client verified pupillary constriction whilst a pen mild become shined of their eyes. Which
nursing action need to the practical nurse perform?
A. Report the finding to the fitness care company.
B. Record the locating at the evaluation notes.
C. Assess blood pressure to rule out hypertension.
D. Record that the patron has negative vision. - ANS-b. Record the finding at the evaluation
notes.
Pupillary constriction to light is a regular locating and should be documented within the
evaluation notes.
A client recognized with a brain tumor is receiving radiation beam treatments to the proper
frontal location. The realistic nurse (PN) have to have a look at this customer for which trouble at
some point of the early post-remedy days?
A. Hemiplegia
b. Headache
,c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a nearby remedy, and most facet consequences are site-specific, along with
infection of surrounding brain tissue, swelling, headache, and fatigue.
A customer identified with a fracture of the left radius has a plaster solid carried out. The nurse
has strengthened instructions for drying the cast over the following 24 hours. Which declaration
with the aid of the patron shows the teaching changed into effective?
A. "I will wrap the solid in plastic wrap for twenty-four hours."
b. "I will aid the forged on a firm surface all through the night."
c. "I will not cowl it; as an alternative I'll maintain the forged surfaces uncovered to circulating
air."
d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch." -
ANS-c. "I will now not cowl it; instead I'll maintain the solid surfaces uncovered to circulating air."
Rationale:
The nurse must train the customer to preserve the solid exposed to circulating air and avoid
covering it with cloth that might keep it wet.
A patron diagnosed with a cranium hematoma and fractured left (L) clavicle following a six foot
fall from a ladder is admitted to the unit. Which signal need to the sensible nurse (PN) file
without delay?
A. Spontaneously opens eyes.
B. Obeys commands in movement and grip.
C. Answers questions, but is burdened.
D. Has abnormal flexion or extension of (L) arm. - ANS-c. Answers questions, however is
confused.
Rationale:
Confusion following a head injury is normally the primary sign of elevated intracranial stress.
A consumer recognized with bacterial meningitis is admitted to the unit and is prescribed neuro
exams each 2 hours. Which manifestation might the practical nurse reveal for that would
provide the first indication of altered neurological function?
A. Change in level of cognizance
b. Increasing muscular weakness
c. Changes in student size bilaterally
d. Progressive nuchal rigidity - ANS-a. Change in degree of focus
A decrease or trade within the stage of attention is typically the primary indication of
neurological deterioration.
A client recognized with persistent obstructive pulmonary disorder complains to the practical
nurse of severe fatigue after coughing. Which self-care measures can assist decrease the
purchaser's dyspnea? (Select all that practice.)
a. Assume a sitting position with shoulders relaxed and knees flexed.
B. Support forearms with a pillow and location both ft flat on the floor.
C. Slightly drop the head, bend ahead, and slowly exhale with pursed lips.
, D. Resume sitting up immediately, the usage of diaphragmatic respiration to inhale slowly and
deeply.
E. Repeat breathing in deeply and slowly with pursed lips even as bending ahead handiest
once.
F. Repeat exhaling and await the cough reflex to facilitate motion of the secretions.
G. After coughing, inhale deeply from stomach and cough 3 or 4 instances while exhaling. -
ANS-a. Assume a sitting function with shoulders at ease and knees flexed.
B. Support forearms with a pillow and region each toes flat on the ground.
C. Slightly drop the top, bend ahead, and slowly exhale with pursed lips.
D. Resume sitting up immediately, the use of diaphragmatic respiratory to inhale slowly and
deeply.
Effective coughing can help the customer to cough secretions, consequently improving fuel
exchange and reduce fatigue. The patron need to anticipate the sitting position with shoulders
relaxed and knees flexed. Their forearms should be supported with a pillow and each ft location
flat on the floor. The client ought to barely drop their head, bent ahead, and slowly exhale
through pursed lips using gradual and deep diaphragmatic breathing to help facilitate powerful
coughing. The patron ought to repeat the previous steps or 3 times. The purchaser ought to
initiate the cough reflex, no longer look ahead to it. The consumer should additionally take a
deep abdominal breath earlier than initiating a cough.
A consumer recognized with diabetic neuropathy has a nonhealing ulcer at the lateral element
in their right (R) foot. Which question should the realistic nurse (PN) ask to gather objective
statistics for the improvement of a diabetic foot care teaching plan?
A. Ask the consumer how they examine their feet.
B. Ask which hypoglycemic medicinal drug they take.
C. Ask to study the pair of footwear they wear.
D. Ask how long they had been diagnosed with diabetes mellitus. - ANS-c. Ask to examine the
pair of shoes they put on.
Rationale:
Asking to observe the consumer's footwear will deliver the most goal facts. The PN desires to
inspect the customer's footwear' inside for any location such as a seam that may be rubbing
against the purchaser foot causing trauma to their ft. Well-geared up footwear are very essential
to save you the development of foot ulcers for the diabetic consumer.
A consumer identified with duodenal ulcers is admitted to the medical institution. The patron
turned into administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding might
imply a healing response of the drugs?
A. Gastric secretions pH level below 3.
B. Hemoccult trying out is high quality on specific activities.
C. No difficulty falling asleep said.
D. No lawsuits of abdominal pain or heartburn verbalized. - ANS-d. No lawsuits of stomach ache
or heartburn verbalized.
Rationale:
Lack of stomach ache within four hours after meals shows decreased duodenal inflammation, a
fantastic outcome within the treatment of duodenal ulcer.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Ashley96. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.99. You're not tied to anything after your purchase.
