Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?
Each evening
Once every shift
Every 4 hours
Every 2 hours
The Correct Answer is D
A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dalmane (flurazepam) is a benzodiazepine used to treat insomnia and is not commonly associated with date rape.
B. Xanax (alprazolam) is a benzodiazepine used to treat anxiety and panic disorders but is not commonly associated with date rape.
C. Narcan (naloxone) is an opioid antagonist used to reverse opioid overdoses. It has no sedative properties and is not associated with date rape.
D. Rohypnol (flunitrazepam) is a potent benzodiazepine that has been used illicitly in cases of sexual assault due to its strong sedative and amnesic effects.
Correct Answer is F
Explanation
A. Insert nasogastric tube: A nasogastric tube may be inserted early to prevent aspiration and manage gastric distension.
B. Initiate fluid therapy: Fluid therapy is crucial and initiated early to combat hypovolemic shock.
C. Insert Foley catheter: A Foley catheter is often inserted early to monitor urine output and assess renal function.
D. Establish airway: Establishing an airway is the highest priority intervention for burn victims, especially if there are signs of inhalation injury.
E. Administer analgesics: Pain management is crucial but is initiated early in the treatment process.
F. Tetanus prophylaxis: Tetanus prophylaxis is important to prevent infection but is typically administered after the immediate life-threatening issues have been addressed.
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