A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
Request a prescription for an indwelling urinary catheter.
Arrange for an alternating pressure mattress.
Apply cornstarch to the client's skin.
Reposition the client every 4 hours.
The Correct Answer is B
An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.
a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not effective.
c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.
d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.
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Related Questions
Correct Answer is B
Explanation
Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.
a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.
d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can affect blood glucose levels.
c. PN and fat emulsions can be administered together in a single infusion.
Correct Answer is ["A","B","D","E"]
Explanation
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
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