A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

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

Massage the client's bony prominences.

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

Reposition the client every 4 hr.

Answer and Explanation

The Correct Answer is A

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

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Correct Answer is B

Explanation

A. Respiratory rate:

Respiratory rate is not part of an anthropometric assessment. Anthropometry primarily focuses on physical measurements related to body size, composition, and proportions.

B. Weight:

Anthropometric assessment involves the measurement of various body dimensions, and weight is a

changes over time, and contribute to the overall understanding of a client's health and well-being.

C. Current pain level:

Pain level is not typically included in an anthropometric assessment. Anthropometry is more concerned with physical measurements and does not directly assess subjective experiences like pain.

D. Level of orientation:

Level of orientation is not a component of an anthropometric assessment. Anthropometry is concerned with objective physical measurements and does not assess cognitive or perceptual factors.

A. Social worker B. Physician assistant C. Physical therapist D. Occupational therapist

Correct Answer is D

Explanation

A. Social worker:

While social workers play a crucial role in addressing various aspects of a patient's well-being, such as psychosocial needs and support systems, they may not be the primary healthcare team member to address the specific issue of a client with severe rheumatoid arthritis being unable to feed herself.

B. Physician assistant:

Physician assistants are medical professionals who work under the supervision of a physician. While they contribute to the overall care of the patient, they may not be the primary specialist for addressing the functional limitations and specific needs associated with severe rheumatoid arthritis.

C. Physical therapist:

Physical therapists primarily focus on physical rehabilitation, movement, and mobility. While they may be involved in the overall care plan for a patient with rheumatoid arthritis, the specific issue of hand function and activities of daily living, such as feeding, is more directly addressed by occupational therapists.

D. Occupational therapist:

The correct choice. Occupational therapists specialize in helping individuals regain or improve their ability to perform daily activities, such as feeding, dressing, and grooming. In the case of severe rheumatoid arthritis affecting the hands, an occupational therapist can work with the client to develop strategies, adaptive equipment, and exercises to enhance hand function and promote independence in activities of daily living.

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A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?

Correct Answer is D

Explanation

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