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's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.

B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.

C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.

D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.

A. Turn on overhead lights briefly when checking IV lines. B. Open curtains between clients in semiprivate rooms. C. Wear shoes with rubber soles. D. Conduct change-of-shift report near the clients' rooms.

Correct Answer is C

Explanation

A. Turning on overhead lights briefly when checking IV lines is incorrect. Bright lights can disrupt sleep cycles, especially for clients who are light-sensitive or have fragmented sleep patterns. Instead, using a flashlight or bedside lamp is recommended to minimize disturbances.

B. Opening curtains between clients in semiprivate rooms is incorrect. Keeping curtains closed provides privacy and helps block light and noise, both of which can interfere with restful sleep.

C. Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.

D. Conducting change-of-shift report near the clients' rooms is incorrect. Shift reports should be conducted away from patient areas to prevent unnecessary noise and disruption during sleep hours.

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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

Naxlex Comprehensive Predictor Exams

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