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 C

Explanation

A. Oranges is incorrect. Oranges are not a choking hazard as long as they are peeled and cut into small pieces for a toddler. The nurse should not include oranges in a list of choking hazards for toddlers.

B. Potatoes is incorrect. Potatoes themselves are not a choking hazard for toddlers, though whole or large pieces could pose a risk. The risk comes from how the food is prepared, not the food itself. If properly cooked and mashed or cut into small pieces, potatoes are safe.

C. Grapes is correct. Grapes are a common choking hazard for toddlers because they are small, round, and can easily block the airway if not properly cut into small pieces. The nurse should definitely include grapes in the pamphlet as a choking hazard.

D. Corn is incorrect. Corn kernels are not typically a choking hazard for toddlers unless they are served as whole kernels, which could pose a risk if not chewed properly. However, corn in the form of pureed corn or small pieces is safe for toddlers to eat.

A. "I can have a meal up to 2 hours before the procedure." B. "I will feel a warming sensation after the injection of the dye contrast." C. "I do not need to sign a consent form before this procedure." D. "I should limit my fluid intake for 2 days after the procedure."

Correct Answer is B

Explanation

A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.

B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.

C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.

D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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