The nurse is caring for a client who is at high risk for development of pressure injury.
The client is able to move independently, but has been placed on bedrest. The client has experienced two episodes of urinary incontinence. Which intervention(s) should the nurse include in the care plan? (SELECT ALL THAT APPLY)

Instruct client to shift their weight at least every 15 minutes

Keep head of bed raised at 45 degrees at all times

Massage over bony prominences every hour while awake

Apply moisture barrier cream to perineal skin

Consult with the wound care nurse about use of a specialty mattress

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale: Instructing the client to shift their weight at least every 15 minutes helps prevent pressure injuries.

Choice B rationale: Keeping the head of the bed raised at 45 degrees at all times is not a typical practice for preventing pressure injuries.

Choice C rationale: Massaging over bony prominences every hour while awake may not be recommended, as this can cause friction and shear, contributing to skin breakdown. Choice D rationale: Applying moisture barrier cream to perineal skin helps protect against skin breakdown from urinary incontinence.

Choice E rationale: Consulting with the wound care nurse about the use of a specialty mattress can provide additional support and help prevent pressure injuries.

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Correct Answer is {"dropdown-group-1":"B"}

Explanation

Choice A rationale: Stage I pressure ulcers involve intact skin with non-blanchable redness, and there is no mention of intact skin in the scenario.

Choice B rationale: Stage II pressure ulcers involve partial thickness skin loss, typically presenting as an abrasion, blister, or shallow crater, which aligns with the description provided.

Choice C rationale: Stage III pressure ulcers involve full-thickness skin loss with damage to or necrosis of subcutaneous tissue but do not match the described scenario.

Choice D rationale: Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, which does not align with the description of partial thickness skin loss in the scenario.

A. inhales slowly to raise the ball to the desired level, and attempts to keep the ball raised for several seconds B. blows into the mouthpiece with a long slow expiration to keep the ball at the base of the spirometer. C. begins breathing with a rapid, forceful inspiration to raise the ball as high as possible. D. exhales slowly to raise the ball to the desired level, and quickly inhales to raise the ball again.

Correct Answer is A

Explanation

Choice A rationale: Inhaling slowly to raise the ball to the desired level and attempting to keep the ball raised for several seconds is the correct technique for using an incentive spirometer.

Choice B rationale: Blowing into the mouthpiece with a long slow expiration is not the correct technique for using an incentive spirometer.

Choice C rationale: Beginning breathing with a rapid, forceful inspiration is not the recommended technique for using an incentive spirometer.

Choice D rationale: Exhaling slowly to raise the ball and quickly inhaling is not the correct technique for using an incentive spirometer.

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Naxlex Comprehensive Predictor Exams

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

Correct Answer is {"dropdown-group-1":"B"}

Explanation

The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

Correct Answer is A

Explanation

The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:

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