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 A

Explanation

A. Encouraging the spouse to share their feelings is the most appropriate initial action. It provides an opportunity for the spouse to express their emotions and begin processing their grief. This approach validates the spouse’s feelings, offers emotional support, and establishes a supportive environment where the spouse can feel heard and understood.
B. Offering reassurance that the spouse is not alone can be comforting, but it may not fully address the immediate emotional needs of the spouse. It is important to first allow the spouse to express their feelings and then provide reassurance as part of the ongoing support.
C. Discussing alternative treatment options may be premature and could be perceived as dismissive of the spouse’s immediate emotional response. At this moment, the spouse is focused on the emotional impact of the terminal diagnosis rather than treatment options.
D. While offering hope can be part of supportive care, this approach might unintentionally minimize the spouse’s current feelings of loss and grief. It can also come across as dismissive of the immediate emotional impact of the diagnosis.

A. Revise clinical practice guidelines. B. Engage staff in evidence based practice. C. Evaluate effectiveness of the change. D. Consult with a clinical nursing expert.

Correct Answer is C

Explanation

A. Revising clinical practice guidelines might be necessary in the long term if the new approach becomes widely accepted and proven effective. However, this action is typically part of a broader, organizational process that follows initial implementation and evaluation.
B. Engaging staff in evidence-based practice is crucial for successful implementation of the new approach. This involves educating and training staff on the new methods, ensuring they understand and support the change, and integrating the new practices into daily routines.
C. Evaluating the effectiveness of the change is a critical next step. After implementing a new approach, it is essential to assess whether it achieves the desired outcomes and improves client care. This evaluation involves monitoring and analyzing results to determine if the change is beneficial and meets the intended goals.
D. Consulting with a clinical nursing expert can be helpful for advice and guidance during the implementation process. However, this action is typically part of the initial planning and decision-making stages rather than the immediate next step after gathering evidence.

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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

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Correct Answer is C

Explanation

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?