A nurse is assisting with the care of a client who has decreased mobility and requires repositioning every 2 hr. Which of the following outcomes should the nurse expect?
The client was discharged to home without developing complications of immobility.
The client returned to the facility 2 days after being discharged due to a urinary tract infection.
The client developed a rash on their back and lower extremities.
The client refuses to eat because they are nauseated.
The Correct Answer is A
A. The client was discharged to home without developing complications of immobility: Repositioning a client every 2 hours is a key intervention to prevent pressure injuries, improve circulation, and reduce the risk of complications such as skin breakdown, deep vein thrombosis, and pneumonia. Achieving discharge without immobility-related complications indicates that preventive measures were effective.
B. The client returned to the facility 2 days after being discharged due to a urinary tract infection: Development of a urinary tract infection shortly after discharge may be related to catheter use, incontinence, or urinary stasis, but frequent repositioning does not directly prevent UTIs. This outcome suggests a complication occurred despite nursing interventions.
C. The client developed a rash on their back and lower extremities: Skin rashes may indicate irritation, allergic reactions, or moisture-associated skin damage. Repositioning helps relieve pressure and reduce friction but does not directly prevent all types of rashes. The appearance of a rash reflects a complication related to skin integrity rather than an expected outcome.
D. The client refuses to eat because they are nauseated: Nausea and refusal of food are unrelated to repositioning frequency. While immobility can contribute to gastrointestinal stasis, this outcome does not reflect the effectiveness of repositioning interventions for preventing pressure injuries or related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Wash your newborn's head under a stream of running water.": Running water directly over a newborn’s head can increase the risk of aspiration or chilling. It is safer to use a damp washcloth to gently cleanse the scalp and hair, controlling the amount of water applied and maintaining the infant’s body temperature.
B. "Bathe your newborn within 30 minutes after a feeding.": Bathing immediately after feeding can increase the risk of spitting up or vomiting due to abdominal distension. It is recommended to wait at least 1 hour after feeding to allow digestion and reduce discomfort during the bath.
C. "Start the bath by washing the newborn's diaper area first.": The bath should always progress from the cleanest areas to the dirtiest areas to prevent the spread of bacteria from the genital region to more sensitive areas like the eyes and face.
D. "The bath water should be 100 to 103 degrees Fahrenheit.": Maintaining the bath water between 100 and 103 degrees is essential to prevent both hypothermia and thermal burns, as a newborn's skin is much thinner and more delicate than an adult's. This temperature range mimics the infant’s internal body temperature, providing a soothing environment.
Correct Answer is D
Explanation
A. "Call a shelter in another county.": While contacting a shelter can be part of a safety plan, specifying another county is not necessary unless there is a need for increased distance from the abuser. The instruction should be individualized, and calling local resources may be more immediately practical and safer.
B. "Leave your partner immediately.": Immediate departure is not always safe and may increase the risk of harm if done impulsively. Safety planning emphasizes strategic, well-thought-out actions rather than abrupt decisions that could escalate danger.
C. "Keep a packed bag by your front door.": Having a packed bag ready is a precautionary measure, but it is only effective if the client also has a safe, rehearsed plan and access to secure transportation. Without a concrete strategy, this step alone may not reduce risk effectively.
D. "Rehearse your escape route.": Practicing an escape route helps the client respond quickly and safely in an emergency situation. Rehearsal allows the client to identify safe exits, plan for transportation, and anticipate obstacles, which is a central component of an effective safety plan for partner violence.
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