A nurse is reinforcing discharge instructions with a client who has hepatitis

Choice A reason: Massaging erythematous bony prominences can actually cause further damage to the skin and underlying tissues. It is better to relieve pressure and monitor the skin closely for any signs of breakdown.

Choice B reason: Implementing a turning schedule every 4 hours is not frequent enough. Clients with spinal cord injuries should be repositioned every 2 hours to prevent prolonged pressure on any one area and reduce the risk of skin breakdown.

Choice C reason: The correct answer is c because using pillows to keep the heels off the bed surface helps prevent pressure ulcers on the heels, which are common sites of skin breakdown in immobilized clients. This technique helps distribute pressure more evenly and reduces the risk of ulcers.

Choice D reason: Keeping environmental humidity less than 30% is not recommended, as low humidity can lead to dry and cracked skin, increasing the risk of skin breakdown. Maintaining a moderate humidity level helps keep the skin hydrated and intact.

Choice E reason: The correct answer is e because minimizing skin exposure to moisture, such as sweat, urine, or wound exudate, helps prevent maceration and skin breakdown. Using moisture-wicking materials and keeping the skin dry and clean are important measures in skin care for paralyzed clients.

Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.

Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.

Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.

Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.

Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.