A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Use an air-assisted device.

Position the bed in reverse Trendelenburg.

Elevate the head of bed to a 45° angle.

Lower the bed close to the ground.

Answer and Explanation

The Correct Answer is A

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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Correct Answer is A

Explanation

A. Respect the daughter's decision to refuse the transfusion.Since the daughter has been designated as the durable power of attorney for health care, she has the legal authority to make medical decisions on behalf of her mother. The nurse should respect her decision, even if it involves refusing treatment.

B. Encourage the daughter to let her mother have the transfusion.While the nurse can provide information and support, they should not pressure or coerce the daughter into making a different decision.

C. Discuss taking guardianship of the client with the facility administration.This is unnecessary as the daughter already has the legal authority to make decisions through the durable power of attorney.

D. Ask the provider to give consent for the transfusion.The provider cannot override the decision made by the designated durable power of attorney unless there is evidence that the daughter is not acting in the client's best interest.

Correct Answer is ["3"]

Explanation

To calculate the volume (mL) that the nurse should administer, we can follow these steps:

Convert the weight from pounds to kilograms.

1 lb = 0.453592 kg
165 lb×0.453592 kg/lb≈74.843 kg

Calculate the total dose using the weight and prescribed dose:

Total Dose (units)=Dose per kg×Weight (kg)
Total Dose=8 units/kg×74.843 kg≈598.744 units

Determine the volume using the concentration of the available solution:

Volume (mL)=Total Dose (units)/Concentration (units/mL)
Volume =598.744 units/200 units/mL ≈ 2.994 mL

Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.

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A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A murse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her ad daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer calcitonin 8 units/kg IM to a client who weighs 165 lb. Available is 200 units/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

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