An 87-year-old client suffered a fall while at home and sustained a right hip fracture. As the client awaits surgery, the healthcare provider (HCP) orders strict bedrest. To prevent complications of immobility, the nurse will complete the following interventions. Select all that apply. One, some, or all options may be correct.

Teach the client to reposition while in bed every 2 hours.

Insert an indwelling urinary catheter.

Encourage the client to consume a diet rich in protein prior to being NPO for surgery.

Administer an anti-diarrheal.

Teach the client to use an incentive spirometer as often as they are able every hour.

Answer and Explanation

Correct Answer : A,C,E

A. Teach the client to reposition while in bed every 2 hours: Regular repositioning relieves pressure on bony prominences and reduces the risk of pressure injuries.

B. Insert an indwelling urinary catheter: Routine use of an indwelling catheter increases risk of urinary tract infection and should be avoided unless there is a clear clinical indication; it is not a first-line preventive measure for immobility complications.

C. Encourage the client to consume a diet rich in protein prior to being NPO for surgery: Adequate protein and nutrition support tissue integrity and wound healing; encouraging nutrient intake while allowed supports recovery and helps prevent malnutrition-related complications.

D. Administer an anti-diarrheal: Anti-diarrheals are not a standard preventive intervention for immobility complications and would not be routinely indicated unless the client has problematic diarrhea.

E. Teach the client to use an incentive spirometer as often as they are able every hour: Incentive spirometry promotes deep breathing, improves lung expansion, and helps prevent atelectasis and pulmonary complications associated with immobility.

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Correct Answer is C

Explanation

A. This is normal for patients who are not turning every 2 hours: Prolonged pressure and lack of repositioning increase risk of pressure injury and tissue necrosis. This is a general statement, not a staging classification.

B. Unstageable pressure injury: An unstageable injury is present when full-thickness tissue loss is suspected but the wound base is obscured by slough or eschar, making depth indeterminate -this description fits wounds covered with thick necrotic tissue.

C. Stage I pressure injury: Stage I involves is characterized by intact skin with non-blanchable redness (erythema) of a localized area, usually over a bony prominence.

D. Eschar: Eschar is dead, leathery, often black or brown tissue that adheres to the wound bed; its presence commonly prompts classification as unstageable until the eschar is removed or the base is visible.

A. Sit beside the client and ask how his care team can best support his spiritual needs. B. Avoid eye contact and call a chaplain for the client to talk to about spiritual matters. C. Place a sign on the door to allow the client some quiet time in the mornings. D. Tell the client that his spirituality is impressive.

Correct Answer is A

Explanation

A. Sit beside the client and ask how his care team can best support his spiritual needs: Sitting with the client, showing presence, and asking an open question honors the client's expressed spirituality and allows the nurse to assess and facilitate appropriate support (e.g., chaplain, family involvement, reading scripture).

B. Avoid eye contact and call a chaplain for the client to talk to about spiritual matters: Calling a chaplain can be appropriate, but avoiding eye contact and withdrawing from the moment neglects immediate emotional support the nurse can provide.

C. Place a sign on the door to allow the client some quiet time in the mornings: Providing privacy may be useful, but it does not respond to the client’s expressed emotion or request in the moment.

D. Tell the client that his spirituality is impressive: Praising or judging the client’s spirituality shifts focus to the nurse’s view rather than supporting the client’s needs; a reflective, empathetic response is more therapeutic.

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Naxlex Comprehensive Predictor Exams

Stage the following:

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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