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1. In a clinical scenario, a nurse is caring for a patient with a decreased level of
consciousness. What intervention should the nurse prioritize to prevent
pressure ulcers?
Administering pain medication
Increasing the patient's fluid intake
Regular repositioning of the patient
Providing heat therapy to the affected area
2. In a scenario where a patient has multiple drains and an old dressing is stuck,
what is the best approach to safely remove the dressing without causing
tension on the drains?
Gently moisten the dressing to loosen it and support the drains
while removing.
Forcefully pull the dressing off to save time.
Remove the dressing without any support to avoid delays.
Cut the dressing around the drains without any additional precautions.
3. What should be done to avoid tension on drains when removing a surgical
dressing?
Use caution to avoid tension on any drains that are present.
Remove the dressing quickly to minimize discomfort.
Soak the dressing in saline before removal.
Apply additional tape to secure the dressing before removal.
,4. In a scenario where a patient is experiencing fecal incontinence, what nursing
intervention should be prioritized to prevent pressure ulcers?
Encourage the patient to eat more solid foods.
Implement frequent skin assessments and maintain skin hygiene.
Limit the patient's mobility to reduce pressure on the skin.
Increase the patient's fluid intake to prevent dehydration.
5. What is the recommended action for pain management after a medial
meniscus repair?
Monitor vital signs every 15 minutes.
Keep the leg dependent.
Apply ice.
Check pulses in the right foot.
6. A patient is using a cold compress for swelling and mentions they will leave it
on for an hour. What should the nurse advise?
The nurse should recommend using it only once a day.
The nurse should advise to limit the application to 15-20 minutes.
The nurse should encourage leaving it on for as long as possible.
The nurse should suggest applying heat instead.
7. Which of the following disease processes would most likely cause delayed or
dysfunctional wound healing?
Hypertension
Diabetes
, Hypothyroidism
Heart disease
8. Which of the following factors is commonly associated with a higher risk of
developing pressure ulcers?
Decreased level of consciousness
High protein diet
Increased mobility
Frequent repositioning
9. A nurse is teaching a client with low back pain about heat therapy. Which of
the following statements by the client indicates a need for further teaching?
I can use hot showers or moist heating pads to promote comfort.
Keeping the heat on my back for 10-30 minutes will help it heal.
I shouldn't turn up the temperature if I can't feel the heat.
I'll sleep on top of the heating pad to increase the heat penetration.
10. Why is it important for the nurse to prioritize the client with appendicitis over
the others?
The client with appendicitis may be at risk for complications,
requiring immediate attention.
The client with an incision that is approximated is stable and requires
less monitoring.
The client with a Braden Scale score of 18 is at low risk for pressure
ulcers.
The client with a Stage IV pressure ulcer needs more frequent
dressing changes.