A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact.

Which of the following interventions should the nurse include in the plan of care?

Apply an occlusive dressing.

Turn and reposition the client every 4 hr.

Support bony prominences with pillows.

Massage the reddened areas three times daily.

Answer and Explanation

The Correct Answer is C

The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.

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Correct Answer is A

Explanation

The aseptic technique is important to prevent infection when changing the dressing of a central venous access device.
Choice B is not correct because povidone-iodine is not always the recommended cleansing agent for central venous access devices.
Choice C is not correct because a 10-mL syringe may generate too much pressure and damage the catheter.
Choice D is not correct because the dressing does not always need to be changed every 24 hours; the frequency of dressing changes depends on the type of dressing and the condition of the site.

A. Glucose level. B. Serum ammonia. C. Serum troponin. D. Phosphate level.

Correct Answer is B

Explanation

This statement indicates an understanding of the teaching because serum ammonia levels can be elevated in liver disease and are used to monitor the progression of liver disease.
Choice A is incorrect because glucose levels are not typically used to monitor liver disease.
Choice C is incorrect because serum troponin levels are used to diagnose heart attacks, not liver disease.
Choice D is incorrect because phosphate levels are not typically used to monitor liver disease.

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A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care?

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A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact.

Which of the following interventions should the nurse include in the plan of care?