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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. “Discontinue the medication. I will ask your provider for another antibiotic.”: This is correct. Ciprofloxacin and other fluoroquinolones are associated with a risk of tendonitis and tendon rupture, particularly in the Achilles tendon. The pain in the calf muscle could indicate this side effect. The nurse should recommend discontinuing the medication and notifying the provider for further evaluation.

B. “That reaction means your dose is too high. Cut the pill in half.”: This is incorrect. The pain in the calf muscle is likely related to a known side effect of ciprofloxacin, rather than the dose being too high. Adjusting the dose is not the appropriate solution.

C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.”: This is incorrect. Calf pain may be indicative of a serious side effect, such as tendonitis or tendon rupture, and the medication should be discontinued until the provider evaluates the client.

D. “This is an allergic reaction. Take the medication with an antihistamine.”: This is incorrect. The pain in the calf muscle is more likely due to tendon-related side effects, not an allergic reaction. Ciprofloxacin-related tendon pain requires immediate attention, and antihistamines would not address the underlying issue.

A. "I will make sure that electrical wires are run under carpeting." B. "I will have the heating system inspected once every 3 years." C. "I will have my hearing tested every 2 years." D. "I will make sure that my hot water faucets are color-coded."

Correct Answer is D

Explanation

A. "I will make sure that electrical wires are run under carpeting.": This is not a safe practice. Running electrical wires under carpeting can lead to the wires overheating or becoming damaged, which is a fire hazard.

B. "I will have the heating system inspected once every 3 years.": The heating system should be inspected more frequently than every three years, ideally annually, to ensure safety and proper functioning.

C. "I will have my hearing tested every 2 years.": While hearing should be monitored regularly, this is not a specific home safety measure. A hearing impairment can increase the risk of falls or accidents.

D. "I will make sure that my hot water faucets are color-coded.": This is an important safety measure, particularly for older adults, as it helps prevent burns. Color-coded faucets can help prevent the risk of hot water burns by easily identifying hot and cold water.

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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?

Nursing Test Bank

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