A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Encourage client fluid intake of 2,500 mL daily.

Moisturize dry skin areas on the client every other day.

Place a dehumidifier in the client's room.

Apply a donut ring pillow under the client's sacral area.

Answer and Explanation

The Correct Answer is A

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

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Correct Answer is A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

A. Add the contents of the capsules to food. B. Dissolve the capsules in a glass of chocolate milk. C. Administer the medication with a glass of orange juice. D. Administer the medication at bedtime.

Correct Answer is C

Explanation

A. Mixing ferrous sulfate capsules with food may alter the absorption of the medication. It is generally recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce

irritation.

B. Dissolving ferrous sulfate capsules in chocolate milk or any other liquid may affect the taste and consistency of the drink. Additionally, chocolate milk may contain substances that could

interfere with iron absorption.

C. Administering iron supplements with a glass of orange juice is a common recommendation because vitamin C enhances the absorption of iron. This combination helps improve the bioavailability of the iron supplement.

D. There is no specific indication to administer ferrous sulfate capsules at bedtime. It is typically recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce irritation.

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A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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