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.

Answer and Explanation

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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Correct Answer is A

Explanation

The correct answer is that the nurse should dangle the client's arm over the edge of the bed to help dilate the vein. This technique uses gravity to increase blood ﬂow to the arm and dilate the veins, making it easier to insert a peripheral IV catheter.

Options b, c and d are not eﬀective techniques for dilating a vein for IV insertion. Stroking the skin near the vein in an upward direction, instructing the client to ﬂex their arm with the hand open and applying a cool compress to the vein for 10 min are not eﬀective methods for dilating a vein.

A. "Let's discuss other areas of your partner's care." B. "I understand how you feel because I recently lost a family member myself." C. "It must be very difficult for you to accept your partner's wishes." D. "You should call your partner's provider to change the DNR order."

Correct Answer is C

Explanation

a) This response may seem dismissive of the partner’s immediate concern about the DNR order and does not directly address their request.
b) While this response attempts to establish a connection through shared experience, it may shift the focus away from the partner's feelings and can come off as self-centered. It may also invalidate the partner's unique experience of loss.
c) This response acknowledges the emotional distress and difficulty the partner is experiencing while validating their feelings. It shows empathy and understanding, which can help build rapport and encourage further communication about the situation.

d)This response is inappropriate because it does not respect the existing DNR order and could create confusion or frustration for the partner. Additionally, changing a DNR order requires specific processes and discussions with the healthcare team.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

Correct Answer is A

Explanation

A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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