An elderly client with a fractured
left hip is on strict bedrest. Which
nursing measure is essential to the
client's nursing care?
A. Massage any reddened areas for
at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally,
prone, and dorsally in sequence.
D. Gently lift the client when moving
into a desired position.
D. Gently lift the client when moving into a desired
position.

To avoid shearing forces when repositioning, the
client should be lifted gently across a surface (D).
Reddened areas should not be massaged

 (A) since
this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range
of motion

(B) may be limited on the affected leg. The
position described in

(C) is contraindicated for a client
with a fractured left hip.

The nurse is administering medications through a nasogastric tube
(NGT) which is connected to suction. After ensuring correct tube
placement, what action should the
nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as
prescribed.
D. Crush the tablets and dissolve in
sterile water.
B. Flush the tube with water.
The NGT should be flushed before, after and in between each medication administered (B). Once all
medications are administered, the NGT should be
clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.

A patient has signed a do-not-resuscitate (DNR) order. If a nurse performs cardiopulmonary
resuscitation (CPR) when the patient stops breathing
and then successfully revives the patient,
the:
a. nurse could be found guilty of battery.
b. patient would have no grounds for legal action.
c. patient could charge the nurse with false imprisonment.
d. nurse could be found guilty of assault.
ANS: A
A nurse who attempts CPR
on a patient who had a doctor's order for a DNR could
be found
guilty of battery.

2. The nurse is aware that the only necrotic wound for
which debridement is not recommended is
a pressure ulcer located on the:
a. scapula.
b. sacrum.
c. heel.
d. femoral head.
ANS: C
Debridement is not recommended for treatment of a
pressure ulcer on the heel
because of the
small amount of tissue available at that site.

3. The nurse clarifies that a vacuum-assisted closure
supports healing of a wound by:
a. drawing the wound edges together by negative
pressure.
b. interrupting the proliferation of bacteria in the
wound.
c. strengthening the wall of the wound.
d. making an air occlusive cover for the wound.
ANS: A
A vacuum-assisted dressing
that is accomplished by a
special dressing and vacuum device
applies negative pressure to
the wound, which increases blood flow, increases oxygenation,
and improves the delivery of
nutrients to the wound.