A nurse is caring for a client who has pneumonia.

Exhibit 1

Medication Administration Record

Day 1, 1500:

Cefazolin 500 mg every 12 hr IV

Dexamethasone 15 mg every 6 hr IV

Day 3, 1200:

Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily

Day 4, 1500:

Discontinue cefazolin 500 mg every 12 hr IV
The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

A. Use a trochanter roll:

A trochanter roll is a positioning device placed alongside the hip to prevent external rotation of the hip joint and maintain proper alignment of the lower extremities. While it is important for maintaining proper hip alignment, it does not specifically address preventing plantar flexion contractures.

B. Use foot splints.

Plantar flexion contractures occur when the muscles and tendons in the foot and ankle become shortened, leading to a fixed downward pointing of the foot. Foot splints are devices designed to maintain the foot in a neutral position, preventing the development of contractures by keeping the ankle dorsiflexed. They help stretch the muscles and tendons in the foot and ankle, preventing them from becoming shortened over time.

C. Apply an abduction pillow to the legs:

An abduction pillow is a positioning device used to maintain proper hip alignment and prevent adduction of the hips and knees. While it is essential for preventing hip contractures and maintaining hip alignment, it does not directly address preventing plantar flexion contractures.

D. Prop the feet up:

Elevating the feet may be beneficial for improving circulation and reducing swelling, but it does not specifically address preventing plantar flexion contractures. In fact, prolonged elevation of the feet without proper support may increase the risk of developing contractures by allowing the foot to remain in a plantar flexed position for extended periods.

A. "I will use the grab bars when getting in and out of the bathtub." - Using grab bars in the bathtub can help prevent slips and falls, promoting safety during bathing.

B. "I need to have a fire escape plan with my family." - Having a fire escape plan is crucial for emergency preparedness and can help ensure the safety of the client and their family in the event of a fire.

C. "I need to set my hot water heater to 140 degrees Fahrenheit." - Setting the hot water heater to 140 degrees Fahrenheit poses a scalding risk, especially for older adults and individuals with sensitive skin. The water heater temperature should be set to a safe and comfortable level, typically between 120 to 130 degrees Fahrenheit, to prevent burns.

D. "I will apply tape over frayed areas of electrical cords." - Applying tape over frayed areas of electrical cords is not a safe practice, as it does not address the underlying issue and may pose a fire hazard. Frayed electrical cords should be replaced promptly to prevent electrical shocks and fires.

E. "I need to check my medications for expiration dates." - Checking medication expiration dates is important to ensure that the medications remain safe and effective for use, reducing the risk of adverse effects or ineffective treatment.