Nursing Care and Interventions Flashcards

A practical nurse is caring for an older adult client with a stage 2 pressure injury on their sacrum. Which nursing intervention is most appropriate for this client?

Answer: Cleanse the wound and apply a moisture-retentive dressing.

A stage 2 pressure injury involves partial-thickness skin loss and requires a moist wound environment to promote healing. Cleansing the wound and applying a moisture-retentive dressing, such as a hydrocolloid or foam dressing, protects the wound and facilitates healing. Massaging the area is contraindicated as it can cause further tissue damage. Dry gauze can adhere to the wound bed, and tight packing is not appropriate for a shallow stage 2 injury.

A practical nurse is preparing to perform nasopharyngeal suctioning on a client. Which action is essential to prevent hypoxia during the procedure?

Answer: Pre-oxygenating the client before suctioning, if indicated.

Pre-oxygenating the client before suctioning helps to increase the client's oxygen reserves, which can prevent or minimize hypoxia that may occur during the procedure when airflow is temporarily obstructed. Suction passes should be limited to 10-15 seconds, and the catheter size should be appropriate (no more than half the internal diameter of the airway) to prevent trauma.

A practical nurse is caring for a client who is 4 hours post-abdominal surgery. The client is hesitant to use the incentive spirometer, stating "it hurts too much to breathe deeply." What is the nurse's most appropriate initial action?

Answer: Teach the client how to splint the incision with a pillow before attempting deep breaths.

Pain is a common barrier to effective post-operative respiratory exercises. Teaching the client to splint the abdominal incision with a pillow provides support, reduces pain during coughing and deep breathing, and enables them to use the incentive spirometer more effectively. This proactive approach addresses the client's concern and helps prevent pulmonary complications like atelectasis.

A practical nurse is preparing to enter the room of a client on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. Which of the following sequences for donning Personal Protective Equipment (PPE) is correct?

Answer: Gown, mask, goggles, gloves

The correct sequence for donning PPE is designed to minimize self-contamination and generally proceeds from the body outwards. The standard sequence is: 1. Gown, 2. Mask or respirator, 3. Goggles or face shield, and 4. Gloves. Gloves are put on last to be pulled over the cuffs of the gown for a complete barrier.

A practical nurse is assisting with feeding a client who has dysphagia following a stroke. Which intervention is a priority to prevent aspiration?

Answer: Positioning the client in an upright, 90-degree angle.

Positioning the client fully upright (90-degree angle or high-Fowler's position) is the most critical intervention to prevent aspiration. This position uses gravity to facilitate the passage of food and liquid down the esophagus and away from the trachea. The client should remain upright for at least 30 minutes after the meal.

A practical nurse is preparing to transfer a client with left-sided weakness from the bed to a chair. Which action demonstrates the correct technique?

Answer: Positioning the chair at a 45-degree angle to the bed on the client's strong (right) side.

To ensure safety and maximize client participation, the chair should be placed on the client's stronger side at a 45-degree angle to the bed. This allows the client to pivot on their strong leg and use their strong arm to reach for the chair, providing stability and reducing the risk of falls.