A nurse is caring for a client.

Exhibit 1

Medical History

0800:

Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension.

Client has a BMI of 32.

Client has a family history of colon cancer.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)

A. Reposition the client every 4 hours:

While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.

B. Raise the head of the client's bed to a 60° angle:

Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.

C. Ensure the client's heels are not touching the mattress.

Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.

D. Massage the client's bony prominences:

Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.

A. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.