A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Assess pressure points every 24 hr.

Turn and reposition the client every 3 hr while in bed.

Teach the client to shift his weight every 15 min while sitting.

Place the client upright ona donut-shaped cushion.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. A financial power of attorney manages financial affairs, not medical decisions. Health care decisions are instead guided by a health care proxy or durable power of attorney for health care, as outlined in the client’s advance directives.

B. The Patient Self-Determination Act upholds the client’s autonomy by allowing them to accept or refuse medical or life-sustaining treatment. This includes the right to decline care, even if such refusal may lead to death, ensuring that personal values and wishes guide end-of-life care.

C. Advance directives can be revised or revoked by the client at any time, regardless of notarization, as long as the client remains mentally competent. The document reflects current wishes and is not legally binding indefinitely.

D. Family members cannot alter a legally valid advance directive. The document represents the client’s own decisions, and only the client can modify or revoke it while competent to do so.

A. Hemothorax B. Cardiac tamponade C. Pulmonary emboli D. Widened pulse pressure

Correct Answer is C

Explanation

Rationale:
A. Hemothorax: Hemothorax is accumulation of blood in the pleural space, typically caused by trauma, surgery, or ruptured vessels. Atrial fibrillation does not directly increase the risk of hemothorax.

B. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, impairing cardiac output. This condition is usually associated with trauma, pericarditis, or post-surgical complications, not atrial fibrillation.

C. Pulmonary emboli: Atrial fibrillation can lead to stasis of blood in the atria, especially the left atrial appendage, increasing the risk of thrombus formation. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, making this a serious complication to monitor for.

D. Widened pulse pressure: Widened pulse pressure reflects the difference between systolic and diastolic blood pressure and is associated with conditions like aortic regurgitation. It is not a direct consequence of atrial fibrillation and is not considered a primary risk in these clients.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?

Correct Answer is B

Explanation

A nurse is admitting a client who has a history of atrial fibrillation. Which of the following conditions should the nurse recognize atrial fibrillation places the client at risk for?

Correct Answer is C

Explanation

A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

A nurse is reviewing the laboratory results for a female client who is receiving furosemide and digoxin. Which of the following findings should the nurse recognize increases the client's risk for developing digoxin toxicity?

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

A nurse is providing teaching to a client who has multiple sclerosis. Which of the following statements should the nurse include in the teaching?

A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?