Which nursing intervention is essential to prevent pressure ulcers in a patient with limited mobility?

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Question 1 of 5

Which nursing intervention is essential to prevent pressure ulcers in a patient with limited mobility?

Correct Answer: A

Rationale: Frequent, thorough skin assessments are essential to prevent pressure ulcers in limited-mobility patients, catching early redness or breakdown for timely intervention. Petroleum jelly doesn't relieve pressure, air mattresses aid but aren't enough alone, and prolonged sitting increases risk. Nurses rely on this to monitor skin health, enabling prompt action like repositioning, crucial for preventing progression to ulcers in at-risk areas.

Question 2 of 5

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:

Correct Answer: B

Rationale: Lead poisoning is treated with chelating agents like succimer or EDTA, which bind lead in the bloodstream, facilitating its excretion and reducing toxicity a standard protocol for elevated blood levels. Gastric lavage or charcoal addresses acute ingestion, not chronic exposure common in children, while antiemetics manage symptoms, not the cause. Nurses explain this to parents, emphasizing chelation's role in reversing neurological and systemic damage, ensuring understanding of the treatment's purpose and process.

Question 3 of 5

A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?

Correct Answer: A

Rationale: A soft abdomen indicates effective nasogastric suction post-bowel resection, decompressing the stomach and intestines, preventing distension or leakage at the anastomosis site. Swallowing ability, bowel sounds, or dressing condition don't directly confirm suction efficacy distension relief does. Nurses monitor this to ensure gastrointestinal rest, reducing complications like ileus or suture strain, supporting healing in a client recovering from major abdominal surgery.

Question 4 of 5

The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?

Correct Answer: D

Rationale: Accurate CMV diagnosis relies on fresh specimens (e.g., urine, saliva), as the virus's viability drops quickly, critical for PCR or culture confirmation unlike stool, pregnant staff safety, or single samples. Nurses ensure prompt lab delivery, protecting immunocompromised clients from missed detection.

Question 5 of 5

A client with a history of renal failure is admitted with shortness of breath and substernal chest pain. Which of the following laboratory values should be reported to the physician immediately?

Correct Answer: A

Rationale: Potassium 6.2 mEq/L (normal 3.5-5.0) in renal failure with chest pain and dyspnea signals hyperkalemia, risking cardiac arrhythmias urgent for physician report. Creatinine elevation is expected, hemoglobin and sodium are normal. Nurses flag this, as it ties to symptoms, prompting ECG and potassium-lowering measures.

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