A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

Massage the client's red bony prominences.

Assess the client's skin for increased coolness.

Reposition the client every 2 hr.

Keep the client's skin moist.

Answer and Explanation

The Correct Answer is C

A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.

B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.

C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.

D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.

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Correct Answer is ["A","B","C"]

Explanation

The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.

A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.

Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.

A. Increased thirst B. Chest pain C. Fever D. Painful urination

Correct Answer is D

Explanation

A. Increased thirst is more commonly associated with dehydration or conditions like diabetes, not urinary tract infections (UTIs).

B. Chest pain is unrelated to UTIs and is more concerning for cardiac issues.

C. Fever can occur with more severe or systemic infections (such as pyelonephritis), but it is not a primary or early symptom of a simple UTI.

D. Painful urination (dysuria) is a hallmark symptom of a urinary tract infection, commonly experienced due to irritation and inflammation of the urinary tract.

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A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

Which of the following is a common symptom of a urinary tract infection?

Correct Answer is D

Explanation

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

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