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 ["A","D","E"]

Explanation

Choice A rationale: Compensating for an ongoing problem affecting other fluid or electrolytes is a common rationale for IV therapy.

Choice B rationale: Increasing urine specific gravity to 1.045 is not a typical goal for IV therapy. IV therapy would decrease the urine specific gravity by diluting the urine with fluids.

Choice C rationale: Moving fluid into an area that is physiologically unavailable is not a primary goal of IV therapy. Physiologically unavailable areas are those that are separated from the rest of the body by a membrane or barrier, such as the cerebrospinal fluid, the intraocular fluid, or the pleural fluid. IV therapy does not cross these barriers and only affects the intravascular and interstitial spaces.

Choice D rationale: Correcting imbalance in fluid and electrolytes is a primary goal of IV therapy.

Choice E rationale: Expanding intravascular volume is a common goal of IV therapy, especially in cases of dehydration or hypovolemia.

A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis E. Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites. Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve. Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle. Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

Correct Answer is C

Explanation

Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites.

Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve.

Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle.

Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

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Naxlex Comprehensive Predictor Exams

The nurse understands that the rationale(s) for clients receiving intravenous (IV) therapy is/are to: (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client. Assuming that there are no skin problems, which is the preferred site for the injection?

Correct Answer is C

Explanation

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