A nurse in a provider's office is caring for a client.

Exhibit 1

Medical History

Initial visit:

Client reports a sedentary lifestyle.

Client is lactose intolerant and denies taking vitamin supplements.

Client is a nonsmoker.

Client does not drink alcohol.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

A. Reposition the client every 4 hours:

While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.

B. Raise the head of the client's bed to a 60° angle:

Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.

C. Ensure the client's heels are not touching the mattress.

Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.

D. Massage the client's bony prominences:

Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.

A. Read the medication label twice prior to administration.

This action is crucial to ensure that the nurse correctly identifies the medication and verifies the dosage before administering it to the patient. By double-checking the medication label, the nurse can confirm that they have the right medication, in the correct dose, for the correct patient, and via the correct route. This practice helps prevent medication errors and promotes patient safety.

B. Use one patient identifier prior to medication administration.

Explanation: Using at least one patient identifier, such as the patient's name or date of birth, is a standard safety practice to confirm the patient's identity before administering any medication. This helps ensure that the medication is given to the right patient, reducing the risk of administering medications to the wrong individual.

C. Access the online drug formulary for an unfamiliar medication.

Explanation: While it's essential to be knowledgeable about medications, relying solely on an online drug formulary for unfamiliar medications may not be sufficient for safe administration. Online resources can provide valuable information, but they should supplement, not replace, comprehensive education and understanding of medications. Nurses should have a solid understanding of the medications they administer and consult additional resources as needed.

D. Ask the client if they have ever taken a similar medication.

Explanation: While it's important to gather information from the patient about their medical history and previous experiences with medications, solely relying on the patient's response may not be sufficient for ensuring safe medication administration. Patients may not always accurately recall or provide complete information about their medication history. Nurses should verify medication orders through appropriate channels and rely on documented medical records whenever possible to confirm medication history and suitability for administration.