The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.
Encourage the client to cough and deep breathe.
Turn client every 2 hours.
Keep skin clean and dry.
Apply lotion to clean skin.
Help the client void.
Correct Answer : A,B,C,D,E
A. Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B. Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C. Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D. Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.
E. Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Normal joint wear and tear typically do not result in bony enlargements, deviation of fingers, or hard, painless joints.
B. Osteomyelitis is a bone infection and would present with symptoms such as fever, localized pain, swelling, and redness over the affected bone, rather than bony enlargements of the joints.
C. Uric acid deposits are associated with conditions like gout and would typically manifest as acute attacks of severe pain, redness, and swelling in the affected joint, rather than the chronic, painless joint deformities seen in the scenario described.
D. Rheumatoid Arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of the synovium, leading to joint deformities, bony enlargements, and deviation of fingers. Joints affected by RA are typically hard, painless, and may exhibit ulnar deviation.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B. Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C. Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D. Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.
E. Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.
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