A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact.
Which of the following interventions should the nurse include in the plan of care?
Apply an occlusive dressing.
Turn and reposition the client every 4 hr.
Support bony prominences with pillows.
Massage the reddened areas three times daily.
The Correct Answer is C
The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Correct Answer is C
Explanation
Leuprolide can cause bone loss, which can lead to osteoporosis and an increased risk of bone fractures.
Choice A, Pallor, is not the correct answer because pallor (pale skin) is not a common side effect of leuprolide.
Choice B, Increased appetite, is not the correct answer because increased appetite is not a common side effect of leuprolide.
Choice D, Hypoglycemia, is not the correct answer because hypoglycemia (low blood sugar) is not a common side effect of leuprolide.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today