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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
A. The client's signs and symptoms, including crackles on auscultation and difficulty breathing, warrant a chest x-ray to assess for possible pneumonia or other respiratory conditions.
B. Obtaining a sputum culture can help identify the causative organism and guide antibiotic therapy for respiratory infection.
C. Antibiotic therapy is indicated for the treatment of respiratory infection, especially if the sputum culture indicates bacterial involvement.
D. There is no indication for inserting a Foley catheter based on the client's signs and symptoms.
E. Nasogastric tube insertion for decompression is not indicated based on the client's respiratory symptoms.
F. Oxygen therapy is indicated for the client's low oxygen saturation level and respiratory distress. Applying oxygen at 2L per nasal cannula can help improve oxygenation.
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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