A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

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Question 1 of 5

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

Correct Answer: A

Rationale: A 79-year-old malnourished client on bed rest is at highest risk for decubitus ulcers, per the document, due to low weight increasing bony prominence pressure, immobility, and poor nutrition impairing skin integrity. Obesity adds pressure but allows mobility. Incontinence risks skin breakdown but is less severe here. Ambulatory status reduces risk. A combines key factors, making it the highest risk.

Question 2 of 5

Which statement best describes the effects of immobility in children?

Correct Answer: B

Rationale: Immobility in children has similar physical effects to adults atrophy, contractures, and skin breakdown occur regardless of age, per physiology. Language/motor delays are developmental, not physical. Greater susceptibility or prolonged immobility lacks evidence here. B accurately reflects consistent immobility effects, making it the best description.

Question 3 of 5

A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?

Correct Answer: D

Rationale: An RN should be assigned an unresponsive client post-MVA. Complex needs (e.g., neuro checks) exceed UAP , student , or PN scope. RN expertise ensures safety during transfer, making D the best assignment.

Question 4 of 5

During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?

Correct Answer: B

Rationale: Reviewing the skills checklist best assesses competence. It objectively verifies abilities post-orientation, unlike supervision needs , comfort , or preferences . B ensures safe assignment, making it the top approach.

Question 5 of 5

A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

Correct Answer: A

Rationale: Explaining dentures must come out is most appropriate. They risk aspiration or damage during anesthesia, per safety protocols. Second thoughts assume unrelated issues. Notification or OR removal delay resolution. A ensures compliance, making it the best intervention.

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