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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Massage over erythematous bony prominences.

Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface.

Implement a turning schedule every 4 hours.

Keep the client's skin dry with powder.

Answer and Explanation

Correct Answer : B,C

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

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Correct Answer is D

Explanation

Choice A reason:

Tennis may not be the best recommendation for someone with low back pain. The sport requires quick lateral movements, sudden stops, and starts, as well as repetitive twisting motions that can exacerbate back pain. While it provides good general exercise, the high-impact nature of tennis and the strain it puts on the back could potentially worsen the client's condition.

Choice B reason:

Canoeing involves repetitive rowing actions that can strain the lower back, especially if the individual does not use proper form. The seated position in a canoe may also put additional pressure on the lower back. Therefore, it might not be the most suitable activity for someone experiencing low back pain.

Choice C reason:

Rowing, similar to canoeing, can place stress on the lower back due to the repetitive motion and the need for strong engagement of the core muscles. If not performed with proper technique, rowing could lead to increased back pain and is not typically recommended for those with existing low back issues.

Choice D reason:

Swimming is often recommended for individuals with low back pain because it is a low-impact exercise that does not put additional stress on the spine. The buoyancy of the water supports the body, reducing the load on the back while allowing for a full range of motion. Swimming can help strengthen the back muscles and improve flexibility, making it a suitable activity for managing low back pain.

A. A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min. B. A client who has a heart rate of 132/min and a respiratory rate of 30/min. C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min. D. A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³). E. A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.

Correct Answer is ["B","C"]

Explanation

Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.

Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.

Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.

Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.

Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.

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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

Correct Answer is D

Explanation

A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

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