In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

4+ pitting edema of both lower extremities.

Hypoactive bowel sounds with infrequent bowel movements.

Braden risk assessment scale rating score of ten.

Warm, dry skin with a fever of 100.0° F (37.8° C).

Answer and Explanation

The Correct Answer is C

A.   Pitting edema, especially at a 4+ level, indicates significant fluid retention in the lower extremities. While this can be a concern for skin integrity and may contribute to skin breakdown due to increased pressure and reduced mobility, it is not the most direct indicator for turning schedules.
B.   Hypoactive bowel sounds and infrequent bowel movements suggest gastrointestinal issues, such as constipation or reduced bowel motility. While these issues are important to address for overall client health, they do not directly impact the scheduling of turning to prevent pressure ulcers.
C.   The Braden Risk Assessment Scale is a tool used to evaluate a client's risk for developing pressure ulcers. A score of 10 indicates a high risk for pressure ulcer development. This assessment directly informs the need for a more aggressive turning schedule and other preventive measures to protect skin integrity.
D.   Warm, dry skin and a low-grade fever might indicate an infection or other underlying condition, but these factors are not the primary considerations for determining the turning schedule. While fever and skin temperature can be important for overall assessment and care, they do not directly impact the need for turning to prevent pressure ulcers.

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Correct Answer is B

Explanation

A. While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B. Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C. This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D. Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

A. A hemoglobin (Hgb) of 11.8 g/dL (118 g/L) and hematocrit (Hct) of 34% (0.34). B. Low weight as determined from a height/weight comparison chart. C. Decreased lean body mass compared to results of 10 years ago. D. Serum albumin of 3 g/dL (30 g/L) and serum transferrin of 180 mg/dL (1.8 g/L).

Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

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In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

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