A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

30° lateral.

Lateral semi-prone recumbent.

Supine.

45° supported Fowler's.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. 30° lateral.

Choice A rationale:

The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.

Choice B rationale:

The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.

Choice C rationale:

The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.

Choice D rationale:

The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.

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Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

A. Justice. B. Veracity. C. Fidelity. D. Autonomy.

Correct Answer is D

Explanation

Choice A rationale:

Justice refers to the fair distribution of resources and benefits. It pertains to treating individuals equitably and ensuring that their rights are respected. However, in this scenario, the nurse is specifically addressing the client's right to refuse treatment, which aligns more with the concept of autonomy.

Choice B rationale:

Veracity is the principle of truthfulness and honesty in communication between healthcare professionals and clients. While it is an important ethical principle, it does not directly relate to the client's right to refuse treatment. This right falls under the principle of autonomy, where individuals have the right to make decisions about their own healthcare, including the decision to refuse treatment.

Choice C rationale:

Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and being dedicated to the well-being of the client. While respecting the client's autonomy is part of being faithful to their needs and preferences, the specific right to refuse treatment is better categorized under the principle of autonomy.

Choice D rationale:

Autonomy is the correct choice. Autonomy emphasizes an individual's right to make decisions regarding their own healthcare based on their values, beliefs, and preferences. In this context, the nurse's responsibility is to uphold the client's autonomy by respecting their decision to refuse treatment. The nurse should ensure that the client has been properly informed about the risks and benefits of the treatment and that their decision is voluntary and informed.

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A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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