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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: A serum magnesium level of 1.8 mEq/L is lower than the normal range and can be associated with alcohol withdrawal.

Choice B rationale: Potassium level within the normal range is not specifically indicative of alcohol withdrawal.

Choice C rationale: Calcium level within the normal range is not specifically indicative of alcohol withdrawal.

Choice D rationale: Phosphorus level within the normal range is not specifically indicative of alcohol withdrawal.

A. stimulate deeper inhalations. B. improve ciliary movement in the bronchioles. C. loosen secretions in congested areas. D. propel oxygen along the respiratory tract.

Correct Answer is C

Explanation

Choice A rationale: Stimulating deeper inhalations is a secondary benefit of CPT, but the primary purpose is to loosen secretions in congested areas.

Choice B rationale: Improving ciliary movement in the bronchioles is a secondary benefit of CPT, but the primary purpose is to loosen secretions.

Choice C rationale: Loosening secretions in congested areas is the primary purpose of CPT for clients with pneumonia.

Choice D rationale: Propelling oxygen along the respiratory tract is not the primary purpose of CPT but may be a secondary benefit.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a diagnosis of alcohol withdrawal. Which serum laboratory value validates the client's admitting diagnosis? A serum:

Correct Answer is A

Explanation

Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:

Correct Answer is C

Explanation

A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Which nursing action is most helpful in thinning a client's thick respiratory secretions?

An adult client is to receive ear drops four times a day to treat an inner ear infection. What is the correct nursing procedure to follow when administering this type of medication?

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.

In providing care for clients, the nurse knows that the normal stimulus to breathe is a/an:

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

The nurse is administering medications to a client who has severe liver damage. Which medications, as ordered below, will avoid the first pass effect? (SELECT ALL THAT APPLY)