A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

Maintain the head of the bed greater than 45°.

Place a donut-shaped cushion under the client’s sacrum.

Massage bony prominences three times daily.

Apply moisturizer to damp skin after bathing.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk.

B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution.

C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma.

D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Explanation

Rationale:

Report of pain: Abdominal pain is common in both cirrhosis and viral hepatitis due to liver inflammation, capsule stretching, or complications like ascites. In hepatitis, pain is often acute and located in the right upper quadrant, while in cirrhosis, it may be more generalized or related to portal hypertension.
Eye sclera finding: Jaundice, noted as yellowing of the sclera, occurs in both conditions due to impaired bilirubin metabolism. In cirrhosis, it's due to chronic hepatocellular failure, while in viral hepatitis, it's from acute inflammation impairing bilirubin excretion.
Alcohol intake history: A 25-year history of heavy alcohol use is a strong risk factor for alcoholic cirrhosis. While alcohol use can worsen viral hepatitis, it is not a primary cause of viral hepatitis, which is due to infection with hepatitis viruses (A, B, C, etc.).
Report of energy level: Fatigue is a common symptom in both conditions due to impaired liver function, toxin accumulation, anemia, or systemic inflammation. In viral hepatitis, fatigue is often sudden and profound, while in cirrhosis, it is usually chronic and progressive.

A. Place the swab in the culture container. B. Ensure the container is labeled with the date and time of collection. C. Apply clean gloves. D. Swab the wound in a zig-zag manner.

Correct Answer is C,D,A,B

Explanation

Rationale:

Apply clean gloves: Wearing clean gloves is the first step to maintain standard precautions and prevent contamination during specimen collection.
Swab the wound in a zig-zag manner: This technique ensures that the swab collects cells and fluid from multiple areas of the wound, increasing the likelihood of detecting any microorganisms present.
Place the swab in the culture container: Immediately inserting the swab into the sterile container maintains the integrity of the specimen and prevents contamination.
Ensure the container is labeled with the date and time of collection: Labeling the specimen is critical for accurate identification and processing by the lab. It must be done after collection to ensure the label reflects the correct time and date.

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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

For each client assessment finding below, click to specify if the finding is consistent with cirrhosis or viral hepatitis: Each finding may support more than one disease process Exhibits

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Explanation

80. A nurse is preparing to obtain a wound drainage specimen for culture from a client who has a nonhealing burn injury. In what order should the nurse collect this specimen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,D,A,B

Explanation

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