A nurse is assisting with the care of a client who has decreased mobility and requires repositioning every 2 hr. Which of the following outcomes should the nurse expect?
The client was discharged to home without developing complications of immobility.
The client returned to the facility 2 days after being discharged due to a urinary tract infection.
The client developed a rash on their back and lower extremities.
The client refuses to eat because they are nauseated.
The Correct Answer is A
A. The client was discharged to home without developing complications of immobility: Repositioning a client every 2 hours is a key intervention to prevent pressure injuries, improve circulation, and reduce the risk of complications such as skin breakdown, deep vein thrombosis, and pneumonia. Achieving discharge without immobility-related complications indicates that preventive measures were effective.
B. The client returned to the facility 2 days after being discharged due to a urinary tract infection: Development of a urinary tract infection shortly after discharge may be related to catheter use, incontinence, or urinary stasis, but frequent repositioning does not directly prevent UTIs. This outcome suggests a complication occurred despite nursing interventions.
C. The client developed a rash on their back and lower extremities: Skin rashes may indicate irritation, allergic reactions, or moisture-associated skin damage. Repositioning helps relieve pressure and reduce friction but does not directly prevent all types of rashes. The appearance of a rash reflects a complication related to skin integrity rather than an expected outcome.
D. The client refuses to eat because they are nauseated: Nausea and refusal of food are unrelated to repositioning frequency. While immobility can contribute to gastrointestinal stasis, this outcome does not reflect the effectiveness of repositioning interventions for preventing pressure injuries or related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreased blood pressure: In acute glomerulonephritis, fluid retention and sodium accumulation often lead to hypertension rather than hypotension. Decreased blood pressure would be unusual and could indicate another underlying issue.
B. Pale yellow urine: Clients typically present with hematuria, which causes tea-colored or cola-colored urine, not pale yellow. The discoloration results from red blood cells leaking into the urine due to glomerular inflammation.
C. Periorbital edema: Fluid retention is common in acute glomerulonephritis, particularly in the face and around the eyes. Edema results from decreased glomerular filtration and sodium/water retention, making periorbital swelling a classic and expected finding.
D. Increased urination: Oliguria, or decreased urine output, is more typical in acute glomerulonephritis due to impaired renal function. Polyuria is not usually associated with this condition unless complications like diabetes insipidus are present.
Correct Answer is D
Explanation
A. 2+ deep tendon reflex: A reflex rating of 2+ is normal and indicates adequate neuromuscular function. In a client receiving magnesium sulfate, this suggests that magnesium levels are within the therapeutic range and are not causing toxicity.
B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate due to vasodilation. While uncomfortable, it is not dangerous and typically does not require intervention unless accompanied by other signs of toxicity.
C. Respiratory rate 13/min: A respiratory rate above 12/min is generally considered within normal limits for adults. Magnesium toxicity becomes concerning when the respiratory rate drops below 12/min, indicating central nervous system depression.
D. Urine output 20 mL/hr: Magnesium sulfate is excreted primarily by the kidneys, and low urine output (<30 mL/hr) increases the risk of magnesium accumulation and toxicity. Reporting this finding allows the provider to adjust the infusion rate or evaluate renal function to prevent serious complications.
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