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 B
Explanation
A. Take her blood pressure twice a day to check for hypertension. Lithium does not typically cause hypertension. Monitoring blood pressure is not a primary concern for patients on lithium.
B. Have her drug blood level checked every month. Regular monitoring of lithium blood levels is crucial to ensure therapeutic levels and avoid toxicity. Lithium has a narrow therapeutic window, and frequent monitoring helps in adjusting the dose to maintain safe and effective levels.
C. Avoid aged cheese and red wine. This advice is relevant for patients taking MAOIs, not lithium. There is no need for patients on lithium to avoid these foods specifically.
D. Examine her skin closely for eruptions. While skin eruptions can be a side effect of some medications, it is not a primary concern for patients on lithium. The focus should be on monitoring for signs of lithium toxicity and other common side effects like tremors, thyroid dysfunction, and renal impairment.
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