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 A

Explanation

A. "I should keep my baby rear-facing in the car seat until she is 2 years old.": This is correct. The American Academy of Pediatrics recommends that infants and toddlers remain in a rear-facing car seat until they are at least 2 years old or until they reach the height and weight limits specified by the car seat manufacturer. Rear-facing provides the best protection for the baby's head, neck, and spine in the event of an accident.

B. "I should position the car seat's retainer clip at the level of my baby's belly button.": This is incorrect. The retainer clip should be positioned at armpit level, not at the belly button. This ensures the harness fits snugly and securely around the baby.

C. "I should enable the airbag when my baby is in the front seat of the car.": This is incorrect. Airbags should never be enabled when a baby is sitting in the front seat, as they can cause injury in the event of a collision. The baby should always be seated in the back seat of the car, as it is the safest location.

D. "I should place my baby in the car seat at a 90-degree angle.": This is incorrect. The car seat should be reclined at an angle of approximately 45 degrees to ensure the baby’s head does not fall forward, which could compromise breathing. A 90-degree angle is too upright and may be unsafe for a newborn.

A. Check the client's vital signs every 4 hr. B. Provide the client with high-calorie finger foods. C. Encourage the client to participate in group activities. D. Allow the client to establish his own schedule.

Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

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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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