A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

Check the client's skin every 4 hr.

Place a donut-shaped cushion under the client.

Turn the client every/hr.

Place the client in a 30° lateral position.

Answer and Explanation

The Correct Answer is D

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

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Correct Answer is C

Explanation

A. "Why would you think a thing like that?": This is incorrect. Asking “why” could make the client feel defensive or that their feelings are being dismissed, which can hinder further conversation. It is important to approach suicidal statements with sensitivity and direct concern.

B. "What would your family do without you?": This is incorrect. While this may seem like a caring response, it places responsibility on the client to think about their family, which may not be helpful if they are feeling overwhelmed by their own emotions. The focus should be on the client’s safety and well-being.

C. "Are you thinking of hurting yourself?": This is correct. It is essential to directly assess the client's safety when they express suicidal thoughts. Asking this question shows concern for the client’s immediate safety and opens the door for further discussion on their feelings and potential plans.

D. "When you get better you will not feel this way.": This is incorrect. This response may dismiss the client’s current feelings and suggests that their emotions are temporary, which could undermine the seriousness of their statements. It is important to validate the client's feelings and address their safety directly.

A. Thrombocytopenia B. Dry cough C. Hypotension D. Hyperglycemia

Correct Answer is C

Explanation

A. Thrombocytopenia: Neither atenolol nor nitroglycerin is commonly associated with thrombocytopenia. This is not the primary concern when these two medications are used together.

B. Dry cough: A dry cough is a known side effect of ACE inhibitors (e.g., enalapril), but it is not commonly associated with atenolol or nitroglycerin.

C. Hypotension: Both atenolol (a beta-blocker) and nitroglycerin (a vasodilator) can lower blood pressure. When taken together, there is an increased risk of hypotension, especially when standing up quickly. The nurse should monitor the client for symptoms of low blood pressure such as dizziness, fainting, or lightheadedness.

D. Hyperglycemia: Atenolol may mask signs of hypoglycemia in clients with diabetes, but it does not directly cause hyperglycemia. Nitroglycerin is not typically associated with hyperglycemia either. Therefore, hyperglycemia is not a concern in this scenario.

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A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

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