A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
"I will perform ankle and knee exercises every hour."
"I will have my partner help me change positions every 4 hours."
"I will remove my antiembolic stockings while I am in bed."
"I will hold my breath when rising from a sitting position."
The Correct Answer is A
A. Regular ankle and knee exercises help prevent muscle atrophy due to immobility.
B. Changing positions every 4 hours is helpful, but more frequent movement is recommended.
C. Antiembolic stockings should be worn when immobile to prevent blood clots.
D. Holding breath during movement doesn't contribute to reducing adverse effects of immobility.
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Related Questions
Correct Answer is C
Explanation
A. Eyewear should be removed after the gown as part of the sequence to prevent exposure to potential contaminants.
B. The mask should be removed after the gown to prevent contamination of the nurse's face.
C. The nurse should follow the sequence of doffing personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) to prevent contamination. The sequence is: gloves, gown, eyewear, and mask. Gloves are the most contaminated piece of PPE and should be removed first by grasping the outside of one glove at the wrist and peeling it off, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the remaining glove at the wrist and peeling it off over the first glove. The nurse should then discard both gloves in a waste container.
D. The gown is removed after the gloves when leaving the room to prevent carrying any potential contaminants outside the patient's room and to maintain infection control measures.
Correct Answer is A
Explanation
A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.
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