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 D

Explanation

A. Tell the client she should discuss this decision with her family.: This is incorrect. While family involvement can be important in decisions regarding treatment, the nurse should respect the client's autonomy and support their right to make decisions about their own care.

B. Discuss alternative treatment methods with the client.: This is incorrect. Since the client has already made the decision to stop dialysis, the nurse should not push alternative treatment methods. The focus should be on supporting the client’s decision rather than presenting options they have chosen not to pursue.

C. Ask the facility chaplain to visit the client.: While a chaplain may provide valuable spiritual support, this is not the first action the nurse should take. It is more important to first support the client’s decision and ensure they are informed about the consequences.

D. Support the client's decision to stop the treatment.: This is correct. The nurse should support the client’s decision and provide care that aligns with the client’s values and wishes. It’s important to respect the client's right to make informed choices about their care, including the decision to discontinue dialysis.

A. Platelet count B. Sputum color C. Temperature D. Fluid intake

Correct Answer is C

Explanation

A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.

B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.

C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.

D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.

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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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Explanation

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