A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Explain to the client that he needs the protein in the milk and the beef.

Allow the AP to deliver the food tray to the client.

Replace the nonfat milk with apple juice.

Call the dietary department and ask for a kosher tray.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Explaining to the client that he needs the protein in the milk and the beef is not an appropriate action. Understanding and respecting the client's religious and dietary preferences are essential. Orthodox Jewish dietary laws, known as kashrut, prohibit the consumption of certain foods, including the mixing of meat and dairy in the same meal. This response disregards the client's faith-based dietary restrictions.

Choice B rationale:

Allowing the AP to deliver the food tray to the client is not appropriate in this situation. The nurse is responsible for ensuring that the client's dietary needs and preferences are met, especially when there are religious considerations involved. Failing to accommodate the client's dietary requirements could lead to non-compliance and potential harm.

Choice C rationale:

Replacing the nonfat milk with apple juice does not address the client's religious dietary restrictions. While the change may avoid mixing meat and dairy, it still disregards the importance of providing a kosher meal. Kosher dietary laws encompass more than just avoiding meat and dairy combinations. It is important to provide a fully compliant kosher meal.

Choice D rationale:

Calling the dietary department and asking for a kosher tray is the appropriate action. A kosher diet adheres to specific rules and regulations, including the separation of meat and dairy products. To respect the client's faith and dietary needs, the nurse should ensure that the food provided aligns with kosher guidelines. This choice demonstrates cultural sensitivity and ensures the client's well-being.

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Correct Answer is A

Explanation

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

A. Patient ate half of his breakfast tray. B. Patient has a raised erythematous rash below the knee. C. Patient has a capillary refill of less than 2 seconds. D. Patient is incontinent of stool.

Correct Answer is D

Explanation

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

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A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Correct Answer is D

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