Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?
A. Encourage the client to bathe frequently.
B. Apply powder to the client's skin.
C. Add moisturizing oil to the client's bath water.
D. Place a humidifier in the client's room.
Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould. Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.
Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.
Similar Questions
A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?
A. Droplet precautions
Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.
B. Airborne precautions
Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.
C. Protective environment
Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.
D. Contact precautions
Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.
Full Explanation
Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.
Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.
Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.
Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?
A. "Advance directives include instructions for resolving financial matters after my death."
B. "Federal legislation dictates the legal guidelines for advance directives."
C. "Advance directives include a living will."
D. "My medical record should not include my advance directives."
A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?
A. Assist the client to the orthopneic position.
It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.
B. Instruct the client to remain as still as possible during the recording.
The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.
C. Attach a blood pressure cuff to the client's upper arm.
Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.
D. Tell the client to expect a mild stinging sensation during the test.
A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client.
Full Explanation
It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.
The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.
Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.
A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client