The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?

Instruct the unlicensed assistive personnel to frequently offer oral fluids.

Prepare to implement a pressure redistribution mattress.

Explain to the client that the wound needs debridement.

Obtain hemoglobin of the side to check for anemia and sensitivity.

Answer and Explanation

The Correct Answer is B

Pressure redistribution is an important part of preventing and treating pressure sores1.

Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.

Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.

Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure

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Free Nursing Study Resources

Correct Answer is ["1"]

Explanation

The nurse should instruct the client to take 1 tablespoon within each dose.

Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled “Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL”, the client should take 15 mL of the suspension per dose.

Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.

A. To ambulate without discomfort. B. To take analgesics as prescribed. C. To show evidence of incision healing. D. To avoid pain-causing activity.

Correct Answer is A

Explanation

The goal of the care plan should be to help the client overcome his activity intolerance related to pain.

This can be achieved by helping him to ambulate without discomfort.

Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.

Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.

Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.

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The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores. What actions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

Correct Answer is ["1"]

Explanation

Correct Answer is A

Explanation

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The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?