A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Receiving bronchodilator medication

Weight loss of 2.8 kg (6.2 b)

Hemoglobin 17 g/dl (12 to 16 g/dL)

Wearing an oxygen device

Answer and Explanation

The Correct Answer is B

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

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Correct Answer is B

Explanation

B. Triiodothyronine (T3) is one of the thyroid hormones, and in Graves' disease, there is excessive production of thyroid hormones, including T3. Therefore, T3 levels are often elevated in individuals with Graves' disease due to the hyperthyroid state.
A. Phosphorus levels are typically not significantly affected by Graves' disease.
C. In Graves' disease, there is typically suppression of TSH secretion due to the negative feedback from elevated levels of thyroid hormones. Therefore, TSH levels are typically decreased (low) in individuals with Graves' disease.
D. Calcium levels are typically not directly affected by Graves' disease.

A. Apply a cold compress to the suprapubic area. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Encourage the client to urinate every 2 hr.

Correct Answer is C

Explanation

A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.

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A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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