The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
Every 30 minutes
Every 180 minutes
Every 60 minutes
Every 120 minutes
The Correct Answer is D
A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.
C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may
still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While calcium supplementation is important for bone health, the recommended daily intake for adults at risk for osteoporosis is typically higher than 250 mg. The client may need a higher dose of calcium supplementation, along with other dietary sources of calcium.
B. While exercise is beneficial for bone health, vigorous exercise may not be suitable for all individuals, especially those at risk for osteoporosis who may have other health
concerns. Moderate-intensity exercise is generally recommended for bone health.
C. Performing moderate-intensity exercise for at least 150 minutes per week is
recommended for individuals at risk for osteoporosis. Weight-bearing and resistance exercises are particularly beneficial for improving bone density and strength.
D. Vitamin D supplementation is important for calcium absorption and bone health, but the recommended daily intake for adults at risk for osteoporosis is typically higher than 400 IU. Many healthcare providers recommend higher doses of vitamin D
supplementation, especially for individuals with low sun exposure or other risk factors for deficiency.
Correct Answer is B
Explanation
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
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