A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Loosen the client's bed linens.

Provide bright lights in the client's room.

Massage the client's sacrum.

Offer to play music in the client's room.

Answer and Explanation

The Correct Answer is D

A. Loosen the client's bed linens:

For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.

B. Provide bright lights in the client's room:

Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.

C. Massage the client's sacrum:

Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.

D. Offer to play music in the client's room:

Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.

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

Explanation

A. Cholesterol level: Elevated cholesterol levels are a risk factor for heart disease. High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol are associated with an increased risk of cardiovascular disease.

B. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, including cholesterol and triglycerides. A history of hyperlipidemia indicates a pre-existing condition that can contribute to the risk of heart disease.

C. History of hypertension: Hypertension (high blood pressure) is a significant risk factor for heart disease. It can lead to damage to the arteries, increasing the risk of atherosclerosis (narrowing and hardening of the arteries) and other cardiovascular complications.

Explanation:

D. History of rheumatoid arthritis: While rheumatoid arthritis is an autoimmune condition that primarily affects the joints, it is not a direct risk factor for heart disease. However, people with rheumatoid arthritis may have an increased risk of cardiovascular disease due to inflammation.

E. Fasting glucose level: The fasting glucose level is related to diabetes rather than heart disease. However, diabetes is a significant risk factor for heart disease, so managing glucose levels is crucial for overall cardiovascular health.

F. Family history: While a family history of heart disease can contribute to an individual's overall risk, it is not a direct finding in the medical record that places the client at risk. The specific risk factors mentioned earlier (cholesterol level, history of hyperlipidemia, and history of hypertension) are more direct indicators of cardiovascular risk.

A. Combine the medications with the formula in the feeding bag. B. Dilute each crushed medication with warm water. C. Mix the medications together in a single syringe. D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration.

Correct Answer is D

Explanation

A. Combining medications with the formula in the feeding bag:

This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.

B. Diluting each crushed medication with warm water:

While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.

C. Mixing the medications together in a single syringe:

This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.

D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:

Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.

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A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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