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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Sore throat: A sore throat can indicate agranulocytosis, a potentially life-threatening adverse effect of clozapine. Prompt monitoring of WBC counts and reporting symptoms such as fever or sore throat is essential to prevent serious infection.
B. Tinnitus: Tinnitus is not a common or severe adverse effect of clozapine. While it may be bothersome, it does not require immediate reporting to the provider in the context of clozapine therapy.
C. Rhinitis: Mild nasal congestion or rhinitis can occur with clozapine use but is generally not dangerous or indicative of a serious complication. Monitoring is routine, but urgent reporting is not required.
D. Headache: Headaches are a common, nonspecific side effect and do not typically indicate a life-threatening reaction. Routine assessment and symptom management are appropriate.
Correct Answer is B
Explanation
Rationale:
A. "Can you tell me more about the surgery I am having?": Before signing consent, the client should already have received complete information about the nature, purpose, risks, and benefits of the surgery from the provider.
B. "Signing this form indicates that I give my permission for the surgery, right?": Informed consent is a legal and ethical document granting permission for the procedure. It shows that the client comprehends their role in authorizing the surgery after receiving adequate information from the healthcare provider.
C. "I will talk with the doctor about my surgery when I get into the operating room.": Consent discussions should occur before entering the operating room. The client must have all questions answered and sign consent prior to sedation or anesthesia to ensure voluntary decision-making.
D. "Every so often, I think about whether or not to have this surgery.": This response suggests indecision and lack of informed readiness for the procedure. The nurse must notify the provider so further discussion can occur to address concerns and ensure the client’s consent is fully informed and voluntary.
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