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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.

B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.

C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.

D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.

A. Headaches with aura B. History of mononucleosis 1 year ago. C. Irregular menstrual cycles D. Gastroesophageal reflux disease.

Correct Answer is A

Explanation

A. Headaches with aura is correct. Headaches with aura, a warning sign that can precede a migraine, are a contraindication for the use of oral contraceptives. This is because oral contraceptives increase the risk of stroke, especially in women who experience migraines with aura.

B. History of mononucleosis 1 year ago is incorrect. There is no specific contraindication for oral contraceptives related to a history of mononucleosis. This condition does not affect the effectiveness or safety of oral contraceptive use.

C. Irregular menstrual cycles is incorrect. Irregular menstrual cycles are not a contraindication for oral contraceptive use. In fact, oral contraceptives may help regulate menstrual cycles.

D. Gastroesophageal reflux disease (GERD. is incorrect. While GERD may cause discomfort, it is not a contraindication for oral contraceptives. Women with GERD can typically use oral contraceptives safely.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?

A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take?

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses. Which of the following statements should the charge nurse identify as an indication that a newly licensed nurse understands utilitarianism?

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?