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concepts of nursing
hesi remediation case study 3
| Question | Answer |
|---|---|
| In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? | A) Apply light pressure to the area with the fingertips B) Measure the diameter of the redness |
| The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? | D) Reactive hyperemia |
| Which areas are most important for the nurse to observe for additional pressure injuries (PI)? | Ischial tuberosities. |
| What action should the nurse implement? | Identify these areas as sites where pressure damage has occurred. |
| Which etiology identified by the nurse is accurate? | C) Impaired physical mobility |
| Which goal should the nurses include in the client's plan of care? | A) Client's skin will remain intact |
| To provide pressure relief at night, the nurse teaches the client to sleep in which position? | Thirty-degree lateral inclined position. |
| Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take? | Encourage them to continue to use this device in their wheelchair at all times. |
| The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI? | A) Transparent film dressing |
| How should the nurse describe the drainage in documenting the wound? | B) Purulent |
| To reduce the effects of moisture on the client's skin, which intervention should be implemented? | A) Apply a moisture-repellent ointment to intact skin areas |
| What action should the nurse take? | D) Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights |
| After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? | Contact precautions. |
| Which equipment should the nurse utilize to assess the length of the tract? | C) Sterile cotton-tipped applicator |
| Which irrigation technique is best? | D) Apply steady pressure using a 35 mL syringe and 19 gauge needle |
| What is the purpose of this type of dressing? | A) Mechanically debride the tissue |
| How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.) | 20 |
| What is the total daily dosage (in mg) that the client will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.) | 800 |
| Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy? | Pharmacist. |
| Which technique should the nurse use to mix the linezolid? | Mix according to directions. |
| The nurse correctly uses which technique when pouring the suspension? | Place the medication cup on a flat surface at eye level. |
| During the course of antibiotic treatment with linezolid, which of the client’s serum laboratory values requires intervention by the nurse? | Platelet count (100 x 103/mcL (100 X 109 /L) |
| The nurse explains to the client that this precaution reduces the risk for what potential problem? | Anaphylactic reaction. |
| Which class of medication should the nurse expect to administer? | An antihistamine, such as diphenhydramine. |
| Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity? | Peak and trough. |
| What initial action should the nurse take? | Offer the client the opportunity to discuss their feelings of anger. |
| Which nursing response best promotes effective communication? | Help the client identify the concerns he is trying to cope with at this time. |
| Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group? | The clients girlfriend and his two best male friends from the college. |
| It is most important to include this group in which aspect of the client's overall care? | Reviewing class notes and studying for exams. |
| The nurse encourages the client to select which breakfast items to provide a good source of protein? | Eggs and orange juice. |
| What teaching should the nurse provide? | Hydrocolloid dressings should be continued over the ulcer. |
Created by:
colby.caswell