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 B

Explanation

Choice A rationale: Iron absorption is influenced by several factors, including the presence of food in the stomach. Food can interfere with iron absorption by forming

insoluble complexes with iron, reducing its bioavailability. Therefore, ferrous sulfate should be taken on an empty stomach, preferably one hour before or two hours after meals, to enhance its absorption and effectiveness.

Choice B rationale: Ferrous sulfate is not destroyed by acid in the stomach but instead acid enhances iron absorption by keeping it in a soluble form.

Choice C rationale: Constipation is a common side effect of iron supplementation, but this is not the primary reason for taking it on an empty stomach.

Choice D rationale: Ferrous sulfate can cause gastrointestinal bleeding in some cases, but this is not the primary reason for taking it on an empty stomach.

A. has a wound that is bleeding. B. has impaired sensation. C. is experiencing spasms of the calf muscles. D. has an active, localized inflammation.

Correct Answer is C

Explanation

Choice A rationale: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.

Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.

Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.

Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.

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Naxlex Comprehensive Predictor Exams

The nurse receives the following order: "Ferrous sulfate 325 mg four times a day PO. Give on empty stomach." Even before researching, the nurse guesses that this is because the medication:

Correct Answer is B

Explanation

The nurse recognizes that the application of heat therapy is appropriate for which client? The client who:

Correct Answer is C

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?

A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states, "I can't catch my breath." Which abbreviation would be used to document this presentation?

A nurse receives an order for blood, urine, stool and nasal cultures on a client with a high fever. Which prefix describes this order?

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

A client is diagnosed with chronic constipation. The nurse is given an order by the physician to administer a glycerin suppository. What abbreviation will be written in the physician's order for the administration route for the suppository?

A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

A group that has transformed itself from a collection of individuals into a productive, problem-solving highly functioning team would be functioning in which stage of group development?