EAQ3

A client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force? 1.maintain the head of the bed at 30 degrees or less. 2.Use draw sheets to pull up, transfer, and position the client. 3.Reposition the client every 2 hours, propping with pillows. 4.Perform passive range-of-motion exercises every 8 hours.

2.

Which key feature is associated with a stage 2 pressure ulcer? 1.Presence of nonintact skin 2.Development of sinus tracts 3.Damage to the subcutaneous tissues 4.Appearance of a reddened area over a bony prominence

1.

Which question would the nurse ask to determine a client's potential for injury because of sleep deprivation? Select all that apply. One, some, or all responses may be correct. 1."Do you operate heavy machinery at work?" 2."What activities do you do in your spare time?" 3."Do you feel the need to take naps during the day?" 4."Does sleepiness affect your performance at work?" 5."How many hours of sleep do you get every night?"

1. 4.

Which sleep disorders are examples of dyssomnias? Select all that apply. One, some, or all responses may be correct. 1.Insomnia 2.Nightmares 3.Sleep terrors 4.Restless leg syndrome 5.Obstructive sleep apnea

1. 4. 5.

the order of pathophysiology involved with the development of pressure ulcers on the sacrum, hips, and ankles of a client with quadriplegia. 1. Reduced tissue perfusionIncorrect 4.Local cell death 5.Development of pressure ulcers 3. Local tissue compression 2.Restriction of blood flow

1. Local tissue compression 2.Restriction of blood flow 3.Reduced tissue perfusionIncorrect 4.Local cell death 5.Development of pressure ulcers

the steps involved in applying a surgical mask in the correct order. -Tie the two lower ties snugly around the neck with the mask well around the chin. -Gently pinch the upper metal band around the bridge of the nose. Find the top edge of the mask. -Hold the mask by its two strings or loops. -.Secure the two top ties at the back of the the head, with the ties above the ears. -Find the top edge of the mask.

1.Find the top edge of the mask. 2.Hold the mask by its two strings or loops. 3.Secure the two top ties at the back of the the head, with the ties above the ears. 4.Tie the two lower ties snugly around the neck with the mask well around the chin. 5.Gently pinch the upper metal band around the bridge of the nose.

The nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1.Loosening of the sutures 2.Sharp increase in serosanguineous drainage 3.Purplish color of the incision 4.Protrusion of organs through an open incision

2

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia? 1.Medication administration procedures 2.Sleep and cognitive changes 3.Dietary measures to be followed at night 4.Nonpharmacological measures, including sleep techniques

2

When taking the history for a client who is being treated for obstructive sleep apnea, which findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. 1.Daytime hypoxemia 2.Chronic fatigue 3.Enlarged tonsils 4.Subcutaneous emphysema 5.Poor concentration

2. 3. 5.

Which nursing action is the priority when the nurse discovers in an admission assessment that a client has a stage 1 pressure ulcer?

Turn the patient every 2 hours

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurse's arms under the client's axillae? 1.Bending and then straightening their knees 2.Bending at the waist and then straightening the back 3.Placing one foot in front of the other and then leaning back 4.Placing pressure against the client's axillae and then raising their arms

1.

Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. 1.Measles 2.Influenza 3.Clostridium difficile 4.Bacterial meningitis 5.Methicillin-resistant Staphylococcus aureus (MRSA

1.

Which statement indicates misunderstanding of the precautions required for clients infected by the Ebola virus? 1."I will isolate the infected client in a private room." 2."I will use standard, contact, and droplet precautions." 3."I will not touch the prepared food for the infected client." 4."I will avoid direct contact with body fluids of the infected client at all times."

3.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. Which would the nurse do initially? 1.Encourage the client to exercise during the day. 2.Arrange a referral for a thorough medical evaluation. 3.Explain that this behavior is an attempt to avoid facing daily responsibilities. 4.Identify that the client is describing clinical findings associated with narcolepsy.

2.

The nurse is planning care to prevent deformities and contractures in a client with burns. When would the nurse begin range-of-motion (ROM) exercises? 1. When pain has lessened 2. When vital signs are stable 3. When skin grafts are healed 4. When emotional status stabilizes

2. When vital signs are stable

Which action to promote sleep would the nurse recommend to a client? 1.Having a snack in bed before trying to sleep 2.Getting out of bed if unable to fall sleep after 20 minutes 3.performing vigorous exercise an hour before bedtime 4.Raising the temperature of the bedroom

2. getting out of bed if unable to fall asleep after 20 mins

Which nursing action helps reduce the development of health care associated methicillin-resistant Staphylococcus aureus (HA-MRSA)? 1.Applying triple antibiotic ointment to puncture sites 2.Bathing clients every other day with soap and tepid water 3. Bathing clients with chlorhexidine gluconate (CHG) solution 4. Performing hand hygiene with soap and water after removing gloves

3.Bathing clients with chlorhexidine gluconate (CHG) solution

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse would document the assessment finding as which stage of pressure ulcer? 1.Stage I 2.Stage II 3.Stage III 4.Unstageable

4.

A registered nurse is teaching a student nurse about factors that influence sleep. Which scenario explained by the registered nurse is an example of a lifestyle factor? 1."A client reports trouble falling asleep because of thinking about stress at work." 2."A client in the intensive care unit has not slept properly because of noises and disturbances." 3."A client who has been taking antidepressants reports drowsiness and lack of sleep." 4."A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night."

4.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. Which is this condition known as? 1.Osteoarthritis 2.Osteoporosis 3.Muscle atrophy 4.Contracture

4.

Which activities would the nurse recommend to a client who asks for advice about insomnia? Select all that apply. One, some, or all responses may be correct. 1.Drink a glass of wine. 2.Engage in vigorous exercise before bedtime. 3.Eat foods containing lysine. 4.Follow the same bedtime ritual each night. 5.Perform deep-breathing exercises.

4. 5.

Which factors may have led to the development of flexion contractures in a client with osteoarthritis (OA)? 1.Wearing shoes without insoles 2.Elevating the legs 8 to 12 inches 3.Using large pillows under the knees or head 4.Placing a small pillow under the head in the supine position

3.

Which nursing interventions would the nurse implement to promote sleep for a client in a health care setting? Select all that apply. One, some, or all responses may be correct. 1.Restrict visitors. 2Reduce lighting. 3.Provide activities during the day. 4.Decrease the sounds of the infusion alarms. 5.Increase the dosage of pain prescriptions at night.

2. 3.

The community nurse is assessing an older adult client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select all that apply. One, some, or all responses may be correct. 1.Instruct the client to apply bedside rails. 2.Encourage the client to wear nonskid shoes. 3.Suggest that the client use an assistive device. 4.Ask the client to install handrails in the bathroom. 5.Help the client rearrange furniture in the house.

2. 3. 5.