A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Insert an indwelling urinary catheter.

Use an alcohol-free barrier product.

Reposition the client every 4 hr.

Massage the skin over bony prominences.

Answer and Explanation

The Correct Answer is B

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

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Correct Answer is D

Explanation

A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.

B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.

C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.

D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.

A. Dispose of the wasted portion of the opioid medication in the sharps box. B. Count the total amount of opioid medication remaining after removing the needed amount. C. Ask a second nurse to witness the discarding of unused opioid medication. D. Report opioid medication count discrepancies to the provider.

Correct Answer is C

Explanation

A. Dispose of the wasted portion of the opioid medication in the sharps box: Opioid medications should never be discarded in the sharps box because it does not ensure proper tracking or accountability. Controlled substances require a witnessed disposal process.

B. Count the total amount of opioid medication remaining after removing the needed amount: While tracking inventory is important, this step alone does not ensure compliance with controlled substance regulations or safe disposal practices.

C. Ask a second nurse to witness the discarding of unused opioid medication: Having a second nurse witness the disposal of any unused portion ensures accountability, prevents diversion, and complies with legal and institutional controlled substance policies.

D. Report opioid medication count discrepancies to the provider: Discrepancies should be reported to the charge nurse or pharmacy according to policy, not directly to the provider. Reporting is part of accountability but not the immediate action during administration and disposal.

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A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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