The nurse delegates a patient's back massage to nursing assistive personnel (NAP). Which statement by the NAP requires the nurse to follow up?

1. "She likes that special lotion her daughter brought. I'll see if she wants me to use it."
2. "The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her.” "
3. "She's been complaining of soreness in her shoulders. I'll give them special attention."
4. "The family usually visits about now. I'll check and see if she wants to wait until later."

 The nurse would not offer back massage to which of the following patients?

1. Patient with abdominal pain 
2. Patient who has a controlled-release transdermal analgesic patch 
3. Patient who receives peritoneal dialysis for renal failure 
4. Patient who is receiving continuous epidural analgesia

Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? 

1. Do not massage any reddened areas on the patient's skin. 
2. Be sure to wash the patient's face with soap. 
3. Disconnect the intravenous tubing when changing the gown. 
4. Wear gloves if necessary.

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up? 

1. "I will check to see if he cleans himself well."
2. "I will let you know if I see any redness or drainage."
3. "I will ask him if he is experiencing any pain in that area"
4. "I will be sure to use hot, soapy water to be sure he's clean."

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?

1. Wear clean gloves during care.
2. Assess the patient's ability to provide self-care.
3. Encourage the patient to report any pain originating from the catheter.
4. Monitor the amount of urine in the drainage bag to prevent overflow.

The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?

1. Assisting the patient into the supine position in bed
2. Cleansing the tip of the penis with a circular motion, starting at the meatus
3. Reserving the cleansing of the tip of the penis as the final step in perineal care
4. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin

When preparing to delegate a patient's back massage to nursing assistive personnel (NAP), the nurse would do what first?

1. Observe the NAP performing the skill
2. Determine if the NAP has enough muscle endurance to give a complete back massage
3. Assess the NAP's understanding of the proper technique for back massage
4. Have the NAP determine whether the patient is interested in a back massage

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response? 

1. "When did you start experiencing the pain?"
2. "Rate the pain on a scale of 1 to 10."
3. "I'll assess your perineal area for the possible cause of the pain."
4. "Would you like some pain medication before I continue with your care?"

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety?

1. Use the call light to ask someone else to bring a washcloth.
2. Raise all four side rails on the patient's bed.
3. Make sure the call light is within the patient's reach.
4. Raise the bed to its highest position.

 As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?

1. Provide all the necessary supplies and linen for this task.
2. Assess the patient's ability to perform proper perineal care.
3. Ensure that the patient has privacy while performing perineal care.
4. Document any complaints of irritation or pain in the perineal area.

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?

1. By avoiding the application of tension on the catheter
2. By patting, not rubbing, the skin dry after thoroughly rinsing it
3. By cleansing the patient's labia from the pubic area toward the rectum
4. By using warm water to cleanse the patient's entire perineal area

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? 

1. Supine
2. Prone
3. Side-lying 
4. Dorsal recumbent

What is the primary reason for performing perineal care on a male patient with incontinence?

1. To provide comfort and a relaxed, refreshed feeling
2. To promote personal hygiene while minimizing perineal odor
3. To remove all microorganisms from the patient's perineal area
4. To reduce the risk of skin breakdown in the patient's genital and perineal area.

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response? 

1. "All right. Just holler when you're ready, and I'll come help you get out of the tub."
2. "Well, I'll check back with you in about 5 minutes to see if you need anything."
3. "That's not safe. I'll wait right outside the door for you to finish."
4. "I'll be back in 15 minutes. That should be enough time for you to finish up."

 A patient with difficulty breathing requests a back massage. In which position would the nurse instruct nursing assistive personnel (NAP) to place the patient during the massage? 

1. Prone 
2. Side-lying 
3. Supine 
4. Fowler’s

When preparing to help a male patient shave, why does the nurse first review the patient’s medical history? 

1. To determine the patient’s risk of bleeding 
2. To see how often he prefers to shave 
3. To learn which is his dominant hand 
4. To determine whether he can perform the task himself

Why would the nurse encourage a male patient to use an electric razor for shaving? 

1. To reduce the use of hospital supplies
2. To reduce the risk of infection 
3. To reduce the risk of bleeding from a disposable razor 
4. To encourage him to shave himself

Which action is most important in minimizing the patient's risk for injury when preparing to shave a patient with a history of bleeding?

1. Fully explain the process to the patient in order to secure his cooperation.
2. Pay particular attention to technique in order to avoid nicks and cuts.
3. Ensure that the provider has ordered the intervention.
4. Review current platelet count and anticoagulation studies.

1. Review current platelet count and anticoagulation studies.

What is the best way for the nurse to ensure that the patient is comfortable while he is being shaved?

1. Administer a prescribed analgesic 30 minutes before beginning the procedure.
2. Gently pull the skin taut in order to avoid nicks and cuts.
3. Ask the patient if he is comfortable several times during the procedure.
4. Encourage the patient to shave himself if he is capable of doing so.

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?

1. Assessing the patient’s gag reflex
2. Inspecting the patient’s oral cavity
3. Placing the bed in a flat position
4. Connecting the suction equipment

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?

1. Upside down, or with the curve facing up 
2. Right side up, or with the curve facing down 
3. With the curve angled toward the patient’s left cheek 
4. With the curve angled toward the patient’s right cheek

When preparing to clean a patient’s dentures using the sink, the nurse first protects the dentures by doing what?

1. Padding the sink basin with a washcloth 
2. Performing hand hygiene 
3. Filling the sink with cold water
4. Filling the sink with hot water

 Under what circumstances would the nurse assume responsibility for providing denture care for a patient? 

1. Assessment of the oral cavity shows mucositis due to chemotherapy.
2. The patient’s previous set of dentures was misplaced or thrown away. 
3. The dentures belong to the hospital or other facility, rather than to the patient. 
4. The patient is unable to care for the dentures on his or her own.

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized? 

1. After breakfast and before going to bed 
2. With morning care 
3. With morning and evening care 
4. After every meal and before going to bed

 What is the primary reason the nurse encourages the patient to participate in hair care? 

1. To free up the staff’s time for patient care
2. To make sure the care is performed according to the patient’s preferences 
3. To encourage the patient’s sense of independence 
4. To allow the nurse to evaluate the patient’s ability to manipulate objects

What is the purpose of parting the patient’s hair into sections?

1. To identify the areas to be groomed
2. To style the hair attractively
3. To check for pediculosis (head lice)
4. To make brushing and combing more effective

For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board?

1. An older adult woman with a drainage tube in place following a mastectomy 
2. An older adult man with a history of bleeding problems 
3. A young woman whose arm and leg have been immobilized on the right side following a car accident
4. A young man who has sustained a fracture of the upper spine in a football game

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness? 

1. Raising the patient quickly into a sitting position after completing a bed shampoo
2. Getting water into the patient’s ears during the rinsing phase of the shampoo
3. Placing the neck in a hyperextended position during the shampoo process
4. Having the entire shampooing process last longer than 15 minutes

For which patient would the nurse most likely ask for a podiatrist consult for nail care? 

1. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot
2. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder
3. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor
4. A 12-year-old girl with a broken foot

1. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)? 

1. The patient prefers that the nurse provide the care. 
2. NAP are not trained to perform foot care. 
3. The patient’s elevated risk of infection makes it unsafe for NAP to perform the care. 
4. The patient’s condition requires that he remain on bed rest.

Which action would the nurse encourage an older adult with foot problems to take at home? 

1. Apply oval pads to treat corns. 
2. Wear socks made of natural fibers. 
3. Carefully shave off calluses with a razor blade. 
4. If a bandage is needed, apply gauze squares with adhesive tape.

In providing foot care, the nurse would soak the feet and hands of which patient? 

1. A 30-year-old man with type 1 diabetes
2. An 86-year-old woman with generalized weakness 
3. A 56-year-old patient with vascular insufficiency who was bathed the day before
4. A 56-year-old patient with vascular insufficiency who was not bathed the day before

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient?

1. To apply moisturizer after air-drying thoroughly
2. To apply moisturizer while the skin is still wet 
3. To skip the moisturizer 
4. To towel-dry thoroughly before applying moisturizer

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure?

1. Administer a prophylactic antibiotic before the procedure, as prescribed.
2. Follow sterile technique during the procedure.
3. Ensure proper hand hygiene before the procedure.
4. Educate the patient in order to minimize movement and talking during the procedure.

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? 

1. Cover the field with a sterile drape before leaving the room.
2. Collect the necessary supplies after preparing a new sterile field.
3. Retrieve the supplies, but instruct the patient not to touch anything on the field.
4. Ask the assistant who has been helping with the procedure to bring the necessary supplies.

 What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field? 

1. “This work surface is too low. Choose a surface that’s above your waist.”
2. “Begin to establish the sterile field here on the overbed table.”
3. “Be careful to touch only the outer 1-inch edge of the sterile drape.”
4. “Remember, reaching over the sterile field constitutes a break in sterile technique.”

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient’s gown. Which action is most appropriate in this situation?

1. Place the sterile supplies only on the portion of the drape that did not touch the gown.
2. Collect the supplies necessary and establish a new sterile field.
3. Determine if the contact occurred within the outer 1-inch perimeter of the drape.
4. Establish the sterile field on the opposite side of the drape.

Why might the nurse offer the patient a bedpan before establishing a sterile field? 

1. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement.
2. A patient’s becoming incontinent constitutes a breach in sterile technique.
3. Refocusing the patient’s attention on a task decreases anxiety.
4. Assessing the patient’s ability to follow instructions will help the nurse maintain the sterile field.

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field?

1. Placing a role of sterile tape on the field 
2. Holding a prepackaged sterile item in the nondominant hand while opening it
3. Adding supplies that will expire in 2 days
4. Placing the needed supplies near the back of the sterile field

A patient requires all of the following interventions. Which one would the nurse perform last?

1. Change the dressing on the patient’s newly established suprapubic catheter.
2. Administer the patient’s prescribed medication.
3. Offer the patient a bedpan.
4. Position the patient for maximum comfort and ease of breathing.

Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? 

1. “Please see to it that nothing contaminates this sterile field while I get some additional supplies.”
2. “I’d like you to make sure that the patient doesn’t reach toward the sterile field while I’m changing the dressing.”
3. “Hand me the item closest to the edge of the sterile field.” 
4. “Place a sterile drape over these supplies for a moment while I answer my other patient’s call light.”

While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? 

1. Nothing 
2. Create a new sterile field 
3. Use sterile forceps to move the gauze pad toward the center of the sterile field
4. Dispose of the gauze before continuing the procedure

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? 

1. Wear clean treatment gloves.
2. Collect supplies with sterile gloves to avoid contamination.
3. Do not allow the wrapper to touch the sterile field.
4. Place the supplies in the 1-inch perimeter of the sterile field.

When adding a sterile liquid to a sterile field, which action will contaminate the field? 

1. Extending your arm over the sterile field to pour the liquid into the receptacle
2. Holding the bottle with the label facing the palm 
3. Adding a liquid with a usable period that expires in 2 days
4. Placing the receptacle 1 inch (about 2.5 cm) from the edge of the sterile field

Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure?

1. Touch only the outer 1½ -inch margin of the sterile field unless you are wearing sterile gloves
2. Avoid splashing when pouring sterile liquids onto the sterile field
3. Compare the label of the solution with the specific solution necessary for the procedure
4. Assess the patient for any known allergies to the sterile solution

What direction would the nurse provide to nursing assistive personnel (NAP) assisting with a sterile procedure in which sterile solutions are being used? 

1. "Hand me that cup of water so I can pour it over my sterile field."
2. "Would you please get me another bottle of sterile water?"
3. "Pour the sterile water into the container at the edge of the field.” 
4. "Open the sterile water bottle and hold the label so that I can see it.”

What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? 

1. Complete the dressing change in a timely manner
2. Collect new supplies and prepare another sterile field
3. Move the lip of the bottle closer to the receptacle when pouring the remaining liquid
4. Reposition the receptacle closer to the edge of the sterile field

When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? 

1. The label is not sterile and will contaminate the field if it is splashed.
2. The label may become illegible if it is splashed.
3. The pour spout faces down when the bottle is held with the label facing the palm. 
4. The hand grips on the bottle are molded to fit correctly when the label is facing the palm.

 What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure? 

1. Sterile prepackaged kits do not have expiration dates.
2. The wrapper of the sterile kit can be used as a sterile field.
3. Adding supplies to the sterile field takes less time than using a prepackaged kit.
4. The prepackaged sterile kit will take up less space on the bedside table.

Which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field?

1. Position the table out of the patient's reach
2. Assess the table for stability
3. Position the height of the table to be above waist level
4. Assemble ahead of time any supplies and equipment not included in the kit.

While opening a prepackaged sterile kit, a package of sterile 4 x 4s falls to the floor. What will the nurse ask ancillary staff to do to ensure the quality of the sterile field?

1. "I will have to set up another sterile field; please take these items away."
2. "Please go to the clean utility room and get me a package of sterile 4 x 4s."
3. "Please watch that nothing contaminates this sterile field while I go and get a replacement item."
4. "Explain to the patient the importance of remaining still during this procedure so no other items are contaminated."

When preparing a sterile field using a prepackaged sterile kit, what will influence the nurse’s placement of the kit on the overbed table?

1. Tips of the flaps are easily accessible.
2. Kit is positioned in the center of the table.
3. Sterile contents of the kit are readily available.
4. Outermost flap can be opened away from the nurse's body.

Prior to setting up a sterile field for a sterile procedure in a patient’s room, why would the nurse ask any visitors to please leave the patient’s bedside? 

1. Ensures that no unnecessary movement occurs that could contaminate the sterile field
2. Limits distractions while setting up the sterile field
3. Ensures a quiet environment during the procedure
4. Provides privacy for the patient

Which action would the nurse perform first when preparing to apply sterile gloves?

1. Perform hand hygiene.
2. Place the package on a stable, flat surface.
3. Assess the glove packaging for wetness or tears.
4. Open the outer packaging.

When are sterile nonlatex gloves recommended for a sterile procedure? 

1. When there is a possible sensitivity issue
2. When the staff member prefers them
3. When latex gloves are not conveniently available 
4. When the patient prefers them

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? 

1. Using powdered sterile gloves
2. Keeping the fingernails trimmed and smoothly filed
3. Selecting the proper glove size
4. Drying the hands thoroughly before applying the gloves

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel (NAP) to position the patient for a sterile dressing change? 

1. Interlocking the fingers and keeping the hands above waist level
2. Keeping the arms at the sides, with elbows bent and gloved hands pointing up
3. Leaving the room momentarily 
4. Stepping back from the bedside where NAP are working

 Which protocol does not vary among institutions? 

1. Acceptability of wearing artificial nails in patient care areas
2. Use of impervious transparent dressings to cover open lesions on nurse’s hands during sterile procedures
3. Use of sterile gloves for sterile procedures
4. Sterile gloves are only available in “one size fits all”

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound? 

1. Remove the dressing, inspect the wound, and reapply a new dressing.
2. Inspect the wound and reapply the surgical dressing every 2 hours. 
3. Inspect the wound, and keep the dressing off until the health care provider arrives. 
4. Wait until the health care provider orders the removal of the surgical dressing.

Which wound would be allowed to heal by secondary intention? 

1. Cleft lip repair
2. Infected hysterectomy incision
3. Exploratory laparoscopy incision
4. Facial laceration caused by a pocket knife

 Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection? 

1. Taking the patient’s temperature
2. Applying clean gloves 
3. Assessing the wound for drainage
4. Assessing the dressing for drainage

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

1. Assessing the site for signs of redness or swelling
2. Reporting the presence of wound odor
3. Removing a soiled outer dressing
4. Opening sterile dressings during the dressing change

The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

1. Osteoarthritis
2. Glaucoma
3. Deafness
4. Diabetes mellitus

When irrigating a wound, how would the nurse know the right amount of pressure to apply? 

1. Calculate the wound size.
2. Follow the general rule of keeping the pressure between 4 and 15 psi.
3. Keep the pressure strong enough to cause moderate pain.
4. Gentle enough that it does not create a splash off of the wound.

Which action should the nurse avoid before irrigating a patient’s foot wound?

1. Assess the patient for a history of allergies to tape and irrigating solution.
2. Review the provider’s orders for the type of irrigating solution to be used.
3. Assess the patient’s pain on a scale of 0 to 10.
4. Warm the irrigant to body temperature in the microwave.

Which device is used for wound irrigation?

1. 19-gauge needle attached to a 10-mL syringe 
2. 19-gauge needle attached to a 35-mL syringe
3. Sterile container held 30.5 cm (12 inches) above the wound
4. Foley irrigating syringe

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

1. White blood cell count
2. Complete blood count
3. X-ray of left foot
4. Culture and sensitivity test

A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

1. Drainage that was not present previously
2. Redness at the abdominal suture line
3. Granulation tissue in the wound bed
4. The patient reports less pain

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?

1. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
2. Use a distraction technique to divert the patient’s attention during the procedure.
3. Position the patient comfortably before the intervention.
4. Thoroughly explain the procedure to the patient.

Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?

1. Begin antibiotic therapy before the dressing change.
2. Use appropriate personal protective equipment (PPE).
3. Adhere to sterile technique during the intervention.
4. Complete the dressing change in an effective, timely way.

What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

1. Notify the surgeon of the bleeding.
2. Remove the dressing, and assess the wound.
3. Assess the patient for signs of shock.
4. Further assess the patient and the wound.

When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

1. After performing hand hygiene at the start of the procedure
2. Before removing the inner dressing
3. After removing the original dressing materials and performing hand hygiene a second time
4. Just before cleansing the wound with sterile water

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

1. Cleansing the wound with sterile water 
2. Blotting the incision with dry gauze
3. Wearing sterile gloves to cleanse the wound
4. Using a new gauze pad for each stroke while cleansing the wound

What is the proper method for cleansing the evacuation port of a wound drainage system?

1. Cleanse it with normal saline.
2. Wash it with soap and warm water.
3. Rinse it with sterile water.
4. Wipe it with an alcohol sponge.

What is the nursing action to set up suction for a hemovac drainage system?

1. Set the suction to lowest level possible.
2. Hemovacs are always set to medium suction.
3. Connect to the wall on intermediate suction.
4. Compress the hemovac, creating suction.

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? 

1. The drainage is odorless.
2. The drainage is straw colored.
3. The patient doesn’t like looking at the drainage tubing.
4. The amount of drainage was greater today than yesterday.

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? 

1. Attach the tubing to the patient’s gown with a safety pin.
2. Tape the tubing to the patient’s bed.
3. Attach the tubing to the nearest side rail.
4. Loop the tubing through the bed frame.

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

1. Pinning the tubing to the patient’s hospital gown
2. Compressing the bulb while replacing the port cap
3. Emptying the drainage container only when it is 90% full
4. Placing the drainage container below the wound site

Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?

1. Begin antibiotic therapy before the dressing change.
2. Use appropriate personal protective equipment.
3. Adhere to sterile technique during the intervention.
4. Complete the dressing change in an effective, efficient manner.

The wound bed of a patient’s pressure ulcer is red. What does this finding indicate to the nurse?

1. Necrotic tissue
2. Presence of slough
3. Granulation tissue
4. Development of an infection

Which measurements would the nurse use to calculate the surface area of a patient’s pressure ulcer?

1. Height and weight
2. Length and width
3. Length and depth
4. Width and depth

How would the nurse safely apply an enzyme debridement ointment?

1. Daub ointment on dead tissue at the wound edges.
2. Put ointment on a tongue blade, and gently spread it on the center of the wound.
3. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
4. Apply a gauze dressing to ensure contact with the ointment.

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient?

1. Reposition the patient at least every 2 hours.
2. Assess the patient’s bony prominences every shift.
3. Educate the family about the importance of healthy skin.
4. Assist the patient in the selection of high-protein foods.

The licensed practice nurse (LPN) provides you with the 

change-of-shift vital signs on four of your patients. Which 

patient do you need to assess first?

1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

2. 54-year-old woman admitted after surgery for fractured 

arm, BP 160/86 mm Hg, HR 72

3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84

4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

A 56-year-old patient with diabetes admitted for communityacquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient’s infection? 

(Select all that apply.)

1. Heart rate

2. Presence of diaphoresis

3. Smoking history

4. Respiratory rate

5. Recent bowel movement

6. Blood pressure in right arm

7. Patient’s normal temperature

8. Blood pressure in distal extremity

1. Heart rate

2. Presence of diaphoresis

4. Respiratory rate

7. Patient’s normal temperature