A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Reposition the client every 2 hours.

Massage the skin over the client's bony prominences.

Position the client in high Fowler's.

Apply cornstarch to keep sensitive skin areas dry.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Repositioning the client every 2 hours is a standard preventive measure to reduce the risk of pressure ulcers. Frequent repositioning helps alleviate pressure on vulnerable areas, improving circulation and preventing skin breakdown. This intervention is widely recommended to maintain skin integrity in at-risk clients.

Choice B reason:

Massaging the skin over bony prominences can cause tissue damage and increase the risk of pressure ulcers. Instead of promoting circulation, it can exacerbate skin breakdown and should be avoided as a preventive measure.

Choice C reason:

Positioning the client in high Fowler's is not specifically related to preventing pressure ulcers. High Fowler's position can help with respiratory issues but does not address pressure redistribution needed to prevent skin breakdown in vulnerable areas.

Choice D reason:

Applying cornstarch to keep sensitive skin areas dry is not an evidence-based intervention for pressure ulcer prevention. Cornstarch can create friction and irritation, potentially worsening skin integrity rather than preserving it.

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Correct Answer is D

Explanation

Choice A reason:

Proceeding to measure the oral temperature immediately after the client has consumed ice chips is incorrect. The cold substance can lower the temperature reading, leading to inaccurate results. The oral temperature measurement would not reflect the client's true body temperature.

Choice B reason:

Documenting that the temperature was not measured is not a practical approach to this situation. While it records the inability to take a measurement, it does not address the need to obtain an accurate temperature reading after an appropriate waiting period.

Choice C reason:

Providing warm water and then measuring the temperature after 5 minutes is not advisable. This method can cause a rebound effect, where the warm water temporarily raises the oral temperature, again leading to an inaccurate reading. It also does not provide a sufficient waiting period for the mouth to return to its baseline temperature.

Choice D reason:

Waiting 30 minutes before remeasuring the oral temperature is the best practice. This period allows the oral cavity to return to its normal temperature, ensuring that the reading is accurate and reflective of the client's true body temperature. It avoids the influence of recent ingestion of cold substances.

A. This drug may be used in maintenance treatment for heart failure. B. This medication may take weeks to see effects. C. Limit use of the drug to 3 days to prevent rebound nasal congestion. D. Take this drug at bedtime because it may cause drowsiness.

Correct Answer is C

Explanation

Choice A reason:

Oxymetazoline is not used for maintenance treatment of heart failure. It is a topical decongestant used to relieve nasal congestion and is not indicated for cardiac conditions.

Choice B reason:

Oxymetazoline provides rapid relief of nasal congestion and does not take weeks to show effects. Its action is almost immediate, making it effective for short-term use.

Choice C reason:

Limiting the use of oxymetazoline to 3 days is crucial to prevent rebound nasal congestion, a condition where the nasal passages become more congested once the medication is stopped. Overuse can lead to dependency and worsening congestion.

Choice D reason:

Oxymetazoline does not typically cause drowsiness, so taking it at bedtime is not necessary. This statement does not apply to the pharmacological effects of this medication.

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A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse is caring for a client currently taking oxymetazoline. Which of the following statements should the nurse include regarding oxymetazoline?

Correct Answer is C

Explanation

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A newly diagnosed epilepsy patient is prescribed diazepam. The nurse understands that this medication causes which of the following adverse effects?

A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

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A nurse is completing an 8-hour intake and output (I&O) record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

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