Sacral Area Client Assignment Help: How to Answer This Question

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Original Question

1) The sacral area of the client is red. During assessment, the nurse gently touched the sacral area with her fingertips and there were no blanching in the area. Based on the data that the nurse collected, what type of injury does the client have? A)Stage 1 pressure injury B)Stage 2 pressure injury C)Abrasions D)Contusions 2)The client is reporting pain in the left lower extremity. The nurse knows that the expert on the level of pain the the client is experiencing is: (Select all that apply) A) the nurse B)the client C) the clients family D)the healthcare provider 3.A nurse is caring for a client with a fever of 103.2°F. The client’s wife asks, “Why does his body get so hot like that?” Which is the best response by the nurse? A)Actually, a fever is often what makes people seek mânical help.” B)”A fever is the body’s way of creating an environment that is harmful to germs.” C)”It is frustrating that his fever is still high when I gave him Tylenol 10 minutes ago.” D)”I think the fever is still up because the antibiotics haven’t had time to work 4) A nurse checked the blood pressure of a patient and was 140/90 when sleeping, and was 110/70 when sitting. How should the nurse interpret? Patient has hypertension Patient has musculoskeletal problem Patient has a hypotension Patient has respiratory distress 5) When taking the blood pressure of a patient, what factors can alter the blood pressure reading? Select all that apply Recent activity Blood pressure cuff size Pt crossing leg when blood pressure is taken Age Check blood pressure above the level of the heart 6) The nurse administering the flu vaccine using a passive needle safety device, after injection. Which of the following actions should the nurse take? Discard the needle into the trash Ensure that the needle retract into the barrel Pull the plastic sheath over the needle Remove the safety device before discarding 7) A patient admitted to the facility you work for pneumonia, you checked her vital sign and were normal. What additional assessment is most relevant to do next? Listen to lung sound Recount respiration for accuracy Asses skin color Asses effectiveness of antibiotics 8) Which of the following are examples of a portal of exit in the chain of the infection? Select all that apply… Sneeze of infected person An infected person Bowel movement of infected person Food that is exposed to infection Nurse who does not wash his or her hands 9) A nurse is taking care of a covid 19 patient who is in isolation. Which position is best for a patient to help speed up recovery. A)Prone B) semi fowler C) side lying D) high fowler 10)The client reported to the nurse during head-to-toe assessment that he could not breathe properly while lying supine with the bed flat. What should the nurse do first? A) Place a nasal cannula with 2 L of 02 B) Assess the O2 saturation C)Document that the patient is unable to breathe D) Raise the head of the bed 11) client has stage 3 pressure ulcers. The wound nurse recommends which of the following dressings for these wounds? A)Hydrocolloid (DuoDERM) B) Transparent film (Opsite) C) Foam dressing (Mepilex) D) Silicone (Mepitel) 12)A nurse is measuring an adult’s client tympanic temperature. Which of the following actions should the nurse take? A) Use a cotton- tipped applicator to remove cerumen B) Put the pinna downward and backward C)Aim the probe posteriorly in the direction of the eardrum D) Insert the probe in with a circular motion 13)The client describes his pain as burning and stabbing. Based on the client’s description of his pain, what type of pain is he experiencing? A)Deep somatic pain B) Visceral pain C) Cutaneous pain D) Neuropathic pain 14)Trevor Solomon has stage 4 colon cancer and he is at home. He is taking prescribed opioid pain medications for the past week and the pain is not responding to the medication. Mr. Solomon pain remains at 10/10 on a pain scale of 0-10. What type of pain is Mr. Solomon experiencing? A)Cutaneous pain B) Neuropathic pain C) Visceral pain D)Intractable pain 15)A client reports waking up frequently during the night and not getting restful sleep. Which response should the nurse make? A) “Perhaps you should try going to bed earlier.” B) “You could try watching TV. That helps me fall asleep.” C)”Drinking alcohol can cause you to wake up during the night.” D) Exercising at night before you go to bed can enhance sleep.” 16)The LP is caring for an elderly client in a LT& facility. Which of the following actions should the nurse take first when assisting with planning the care plan? A)Set up physical therapy B)Know how the client’s mobility C) Explain the role of the CNA D)Evaluate the client’s routine for home care 17)A client asks why the shoulder is hurting when the problem is in the abdomen. Which type of pain should the nurse explain this client is experiencing? A) Refored B)Radiating C) Intractable D)Intermittent 18)The LPN is caring for a client with MRSA in the client’s left hip surgical wound. Which of the following should the nurse do? A)Allow the client smoke breaks B)Allow the client to ambulate in the hallway every hour C) Allow the client to ambulate in the hallway once per shift D) Order supplies and equipment to use with the client 19)The nurse knows that which of the following are factors that affect the body’s ability to defend itself against infection? (Select all that Apply) A)Good nutrition B)Lack of rest C) Age D)Chronic illness E)Exercise

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