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 D

Explanation

A. A small amount of red drainage is expected immediately after surgery.

B. A shiny, moist stoma indicates healthy tissue and is a normal finding.

C. A rosebud-like appearance of the stoma is expected for a newly created colostomy.

D. A purplish-colored stoma is a sign of compromised circulation and possible necrosis, which requires immediate medical attention.

A. Urine specific gravity of 1.015 B. Cloudy urine C. Urine osmolality of 200 mOsm/kg D. Dark-colored urine

Correct Answer is D

Explanation

A. A urine specific gravity of 1.015 is within the normal range, so it is not indicative of dehydration.

B. Cloudy urine may indicate infection but is not a hallmark sign of dehydration.

C. A urine osmolality of 200 mOsm/kg is low and more consistent with overhydration rather than dehydration.

D. Dark-colored urine is a common sign of dehydration, as concentrated urine results from reduced fluid intake.

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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

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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