While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Avoid friction when sliding up in bed.

Offer supplemental nutritional snacks.

Change bed pads to keep skin clean and dry.

Change position frequently from right to left.

Answer and Explanation

The Correct Answer is D

A.   While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B.   Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C.   While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D.   The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

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Correct Answer is D

Explanation

A. Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B. While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C. Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D. Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.

A. Increase fiber in diet and add daily prune juice. B. Assess type and frequency of physical activities. C. Perform a digital examination for fecal impaction. D. Check bowel sounds and abdominal tenderness.

Correct Answer is D

Explanation

A. Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B. Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C. A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D. Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

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While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?