A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Reposition the client every 3 hours.

Apply cornstarch to keep the skin dry.

Provide the client with a diet high in protein.

Massage bony prominences to promote circulation.

Answer and Explanation

The Correct Answer is C

A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.

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Correct Answer is B

Explanation

The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.

A. The client's urinary output will be increased. B. The client's urine will be a medium-amber color. C. The client's urine will have a strong ammonia odor. D. The client's urinary output will be decreased.

Correct Answer is A

Explanation

A diuretic is a medication that increases the production of urine by the kidneys. This can help reduce swelling (edema) by removing excess ﬂuid from the body. If a client is prescribed a diuretic for swelling of the lower extremities, the nurse should teach the client that the medication will increase their urinary output. This means that the client will need to urinate more frequently and may produce more urine than usual. The color and odor of the urine may also change, but these changes are not directly related to the eﬀect of the medication on urinary output.

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A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Correct Answer is B

Explanation

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

Correct Answer is A

Explanation

A client is hospitalized with numerous acute health problems. According to Maslow's hierarchy of needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

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A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

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