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A nurse is caring for a client in a medical-surgical unit.

After reviewing the assessment findings, which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.

Teach the client to shift their weight every hour when sitting.

Assist the client to dangle their legs at the bedside prior to standing.

Massage the client's lower legs to promote circulation.

Perform passive range of motion exercises once a day.

Delegate the application of sequential compression devices to assistive personnel.

Encourage the client to bear down when moving up in bed.

Administer analgesic prior to planned activities.

Answer and Explanation

Correct Answer : A,B,G

A. Teach the client to shift their weight every hour when sitting: After knee replacement surgery, prolonged pressure on the same area can impair circulation and increase the risk of pressure injuries. Teaching the client to shift weight regularly promotes blood flow, reduces prolonged pressure on tissues, and supports skin integrity.

B. Assist the client to dangle their legs at the bedside prior to standing: Dangling the legs before standing helps the body gradually adjust to positional changes and reduces the risk of orthostatic hypotension. The client’s blood pressure decreased to 92/64 mm Hg at 0930, suggesting possible postural instability. Allowing time for cardiovascular adjustment promotes safety and reduces the risk of dizziness or falls during early ambulation.

C. Massage the client's lower legs to promote circulation: Massaging the lower legs is contraindicated for postoperative clients, especially those at risk for deep vein thrombosis. Manipulating the calf muscles could potentially dislodge a thrombus and lead to a pulmonary embolism. Circulation should be promoted through ambulation, compression devices, and leg exercises.

D. Perform passive range of motion exercises once a day: Passive range of motion exercises are typically indicated for clients who are unable to move their extremities independently. A postoperative knee replacement client who is alert and preparing for physical therapy should participate in active or assisted range of motion exercises as directed by the therapy team. Performing passive exercises only once daily would not adequately support rehabilitation.

E. Delegate the application of sequential compression devices to assistive personnel: Applying sequential compression devices requires assessment of skin integrity, proper placement, and evaluation of circulation. These responsibilities require nursing judgment, particularly in a postoperative client who is at risk for circulatory complications.

F. Encourage the client to bear down when moving up in bed: Bearing down involves performing a Valsalva maneuver, which can increase intrathoracic pressure and reduce venous return to the heart. This can lead to sudden drops in blood pressure and potential cardiovascular strain. Postoperative clients should be instructed to exhale during exertion rather than holding their breath.

G. Administer analgesic prior to planned activities: Providing pain medication before physical therapy or mobility activities helps control procedural and movement-related pain. Effective analgesia improves the client’s ability to participate in rehabilitation exercises and ambulation, which are critical for recovery after knee replacement surgery.

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Correct Answer is ["A","B","C","F","G"]

Explanation

A. Temperature: A temperature of 38.3°C (101°F) indicates fever, which can signal a systemic inflammatory response or infection. In a client with a pressure injury that has developed purulent drainage and foul odor, fever raises concern for wound infection or possible systemic spread. This finding requires prompt provider notification for potential antibiotic therapy and further evaluation.

B. WBC count: A WBC count of 12,000/mm³ is elevated above the normal range and suggests an inflammatory or infectious process. In the context of a worsening pressure injury with purulent drainage, leukocytosis supports the possibility of an active infection. Reporting this finding allows the provider to consider diagnostic tests and treatment such as wound cultures or antimicrobial therapy.

C. Prealbumin level: The prealbumin level of 12 mg/dL is below the normal range, indicating poor nutritional status. Adequate protein and caloric intake are essential for wound healing and tissue regeneration. Low prealbumin can impair the healing of pressure injuries and may require nutritional intervention, supplementation, or referral to a dietitian.

D. Hemoglobin level: The hemoglobin level of 13 g/dL falls within the normal reference range for adults. Adequate hemoglobin supports oxygen delivery to tissues, which is important for wound healing. Because this value is within normal limits, it does not require reporting as an abnormal finding.

E. Blood pressure: The blood pressure reading of 128/64 mm Hg is within an acceptable range and does not indicate hemodynamic instability. There are no signs of hypotension or hypertension that would compromise tissue perfusion or indicate acute deterioration. Therefore, this value does not require immediate reporting.

F. Pain level: The client’s pain has increased from 2/10 on Day 1 to 6/10 on Day 4, indicating worsening discomfort. Increasing pain in a pressure injury may signal infection, tissue deterioration, or inflammation. This change in pain level should be reported because it represents a significant clinical change requiring reassessment of wound management and pain control.

G. Odor of wound: A foul odor from a pressure injury is commonly associated with bacterial infection or necrotic tissue. When combined with purulent drainage and yellow wound tissue, it strongly suggests wound deterioration and possible infection. This finding should be reported promptly for evaluation and potential treatment adjustments.

H. Bowel sounds: Active bowel sounds in all four quadrants indicate normal gastrointestinal motility. This is a normal assessment finding and is unrelated to the client’s pressure injury status. Because it does not represent a complication or abnormal change, it does not need to be reported to the provider.

A. Place the client in high-Fowler's position. B. Have the client use a trapeze bar when changing position. C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion. D. Increase the client's intake of carbohydrates.

Correct Answer is B

Explanation

A. Place the client in high-Fowler's position: High-Fowler’s position (sitting at 60–90 degrees) can increase pressure on the sacrum and coccyx, which are common sites for pressure ulcers. While upright positioning may help with respiratory function, it does not prevent skin breakdown and may actually contribute to pressure-related injury if repositioning is not frequent.

B. Have the client use a trapeze bar when changing position: A trapeze bar allows the client to lift and reposition themselves independently, reducing friction and shear forces on the skin. By enabling weight redistribution and promoting mobility, it helps prevent pressure ulcers in bony prominences and enhances circulation, which is essential for skin integrity in clients with limited lower extremity mobility.

C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion: Massaging areas of darker or reddened skin can cause further tissue damage by disrupting already compromised capillaries. The recommended approach is to relieve pressure, maintain skin hygiene and use protective padding, rather than massaging areas at risk for breakdown.

D. Increase the client's intake of carbohydrates: Adequate nutrition supports overall healing, but carbohydrates alone do not directly prevent skin breakdown. Protein and vitamins (such as vitamin C and zinc) are more critical for tissue repair and maintaining skin integrity. Nutrition is a supportive measure rather than a direct preventive intervention for pressure ulcers.

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A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings, which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Correct Answer is ["A","B","C","F","G"]

Explanation

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

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A nurse is caring for a client in a medical-surgical unit.

After reviewing the assessment findings, which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.