A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?
Check the client's skin every 4 hr.
Place a donut-shaped cushion under the client.
Turn the client every/hr.
Place the client in a 30° lateral position.
The Correct Answer is D
A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.
B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.
C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.
D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.
B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.
C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.
D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.
Correct Answer is C
Explanation
A. “I will follow a full-liquid diet the day before the procedure.": This is incorrect. Typically, clients are instructed to follow a clear-liquid diet the day before a colonoscopy, not a full-liquid diet. Clear liquids (e.g., water, broth, clear juices) are required to ensure the colon is fully cleaned out for the procedure.
B. “This procedure will take place while I'm under general anesthesia.”: This is incorrect. A colonoscopy is usually performed with moderate sedation or conscious sedation, not general anesthesia. The client may be sedated but will not be completely unconscious.
C. “I have my friend drive me home after the procedure.”: This is correct. After a colonoscopy, the sedation used for the procedure can impair the client's ability to drive. It is recommended that the client arrange for a friend or family member to drive them home.
D. “I can expect rectal bleeding for a week after the procedure.”: This is incorrect. Mild rectal bleeding can occur immediately after the procedure, but it should not last for a week. If bleeding persists beyond a day or two, the client should contact their healthcare provider.
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