A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?
Provide the client with high-protein meals.
Gently massage the reddened areas.
Place the client in a supine position.
Use hot water when cleaning the client's skin.
The Correct Answer is A
Rationale:
A. Provide the client with high-protein meals: High-protein meals are important for tissue repair and healing, especially in clients at risk for pressure ulcers. Adequate nutrition, including protein, is essential to promote skin integrity and prevent further skin breakdown.
B. Gently massage the reddened areas: Massaging reddened areas can increase tissue damage and worsen skin breakdown. Instead of massaging, the nurse should relieve pressure on those areas to prevent further injury.
C. Place the client in a supine position: The supine position might increase pressure on the client's scapulae. It is better to reposition the client to relieve pressure from affected areas, ideally by turning them to their side or using pillows to offload pressure.
D. Use hot water when cleaning the client's skin: Hot water can dry and irritate the skin, worsening the condition. The nurse should use lukewarm water and gentle, non-irritating products to clean the skin and prevent further damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "Discontinue opioids before trying nonpharmacological methods of pain relief."
Nonpharmacological methods should complement, not replace, opioids. It's important to continue prescribed medications and incorporate nonpharmacological techniques to manage chronic pain.
B. "Distraction changes the client's perception of pain, but it does not affect the cause."
Distraction techniques, like listening to music, can alter pain perception by redirecting attention, but they do not address the underlying cause of pain.
C. "Use imagery with clients who have difficulty with focus and concentration." Imagery is a relaxation technique that requires focus. It may not be effective for clients with concentration difficulties, as they may struggle to benefit from this method.
D. "Pain relief from the use of heat and cold continues for several hours after removal of the stimulus." Pain relief from heat and cold is temporary and typically fades once the stimulus is removed. It provides short-term relief and should not be expected to last long after application.
Correct Answer is A
Explanation
Rationale:
A. PaCO2 48 mm Hg (35 to 45 mm Hg): In COPD, the body may have difficulty exhaling carbon dioxide, leading to elevated PaCO2 levels. A PaCO2 of 48 mm Hg indicates hypercapnia, especially in advanced stages where respiratory function is impaired.
B. HCO3- 25 mEq/L (21 to 28 mEq/L): HCO3- (bicarbonate) is within the normal range in the acute phase of COPD exacerbation. However, in chronic cases of COPD, bicarbonate levels may increase as the kidneys compensate for respiratory acidosis over time.
C. PaO2 85 mm Hg (80 to 100 mm Hg): A PaO2 of 85 mm Hg is within the normal range, but in clients with COPD, oxygen levels are often lower due to impaired gas exchange. It is common to see PaO2 values closer to or below 60 mm Hg in individuals with COPD.
D. pH 7.38 (7.35 to 7.45): A pH of 7.38 is normal and does not indicate acid-base imbalance. COPD clients often have a tendency towards respiratory acidosis, which may lower the pH, especially during exacerbations, but this value is not concerning for an acute problem.
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