A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use warm water when bathing the client.

Place a donut-shaped cushion in the client's chair.

Massage reddened areas over bony prominences.

Maintain the client in high-Fowler's position.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Use warm water when bathing the client.

Choice A rationale:

Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.

Choice B rationale:

Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

Choice C rationale:

Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

Choice D rationale:

Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

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Correct Answer is C

Explanation

The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”

Choice A rationale:

Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.

Choice B rationale:

Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.

Choice C rationale:

Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.

Choice D rationale:

Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.

A. An insurance agency offering a life insurance policy. B. A family member who requests the client's diagnosis. C. A physical therapist who is involved in the client's care. D. An employer completing a pre-employment screening.

Correct Answer is C

Explanation

The correct answer is choice C: A physical therapist who is involved in the client's care.

Choice A rationale:

Disclosing health information to an insurance agency offering a life insurance policy typically requires the client's written permission due to the sensitive nature of the information being shared, including medical history and conditions.

Choice B rationale:

Revealing a client's diagnosis to a family member without written consent would violate the client's privacy rights. Health information is protected by privacy laws, and disclosure should only occur with the client's explicit permission.

Choice C rationale:

This is the correct entity to whom health information can be disclosed without the client's written permission. Health professionals who are actively involved in the client's care, such as a physical therapist, are considered part of the healthcare team and may need access to relevant health information for proper treatment.

Choice D rationale:

Disclosing health information to an employer completing a pre-employment screening generally requires the client's consent, as pre-employment screenings often involve sharing medical information that could impact the employment decision.

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A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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