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 B

Explanation

A. The client should use a hair dryer on a warm setting to relieve itching inside the cast is incorrect. Using a hair dryer could cause skin burns or damage the cast. Additionally, the client should avoid introducing moisture into the cast, which could lead to skin irritation or infection.

B. The client's extremity should be elevated after the cast is applied is correct. Elevating the extremity helps reduce swelling and inflammation during the initial phase after cast application. It is important to elevate the limb above the level of the heart to promote venous return and reduce swelling.

C. The client can shower with the cast after 24 hr is incorrect. The plaster cast should not get wet. The nurse should instruct the client to keep the cast dry at all times. A plastic cover or cast protector should be used when showering to prevent moisture from seeping into the cast.

D. The client should keep the cast covered until it is dry is incorrect. It is true that the cast should be kept dry, but keeping it covered is not enough. The primary concern is preventing moisture and ensuring the plaster cast is allowed to air dry in a well-ventilated area without getting wet.

A. "Eat 40 milligrams of protein-rich foods per day." B. "Increase your dietary intake by 500 calories per day." C. "Consume 600 micrograms of folic acid per day." D. "Limit your caffeine intake to 700 milligrams per day."

Correct Answer is C

Explanation

A. "Eat 40 milligrams of protein-rich foods per day.": Protein intake is important during pregnancy, but 40 milligrams is an unusually low amount. The recommended amount is generally higher, around 71 grams of protein per day during pregnancy.

B. "Increase your dietary intake by 500 calories per day.": The general recommendation for calorie increase during pregnancy is about 300 calories per day, not 500. 500 calories per day may be recommended in specific situations, but it is not the typical guideline.

C. "Consume 600 micrograms of folic acid per day.": This is the correct recommendation. The CDC and other health guidelines recommend that pregnant individuals consume 400-600 micrograms of folic acid daily to prevent neural tube defects.

D. "Limit your caffeine intake to 700 milligrams per day.": Caffeine intake should generally be limited to around 200-300 milligrams per day during pregnancy, not 700 milligrams, as high caffeine intake can have adverse effects on pregnancy outcomes.

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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?

Nursing Test Bank

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