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. 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. Administer the client's insulin dose using a tuberculin syringe:

While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.

B. Use a filter needle when withdrawing medication from the multidose vial:

While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.

C. Verify the dose of insulin with another nurse once it is prepared.

Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.

D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:

Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an