Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Applies powder after drying the skin.

Has been NPO for four days.

Bathes twice a week.

Has hypertension.

Answer and Explanation

The Correct Answer is B

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

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Correct Answer is B

Explanation

This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.

Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.

Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.

Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.

A. Apply them safely and secure to the bed rails. B. Use to protect elderly patients from pulling out tubes and lines as soon as you place them. C. Apply them to clients who have a history of violence or a previous fall for everyone’s protection. D. Use them only as a last resort after attempting alternatives and get an order to do so.

Correct Answer is D

Explanation

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

Check the person at least every 15 minutes
Remove restraints and meet basic needs at least every 2 hours
Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

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Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which outcome is expected for a client who has a diagnosis of constipation? The client:.

Correct Answer is B

Explanation

When using wrist restraints, which of these statements is correct?

Correct Answer is D

Explanation

Which statement, if made by a client diagnosed with sleep disturbance, should a nurse evaluate as correct understanding of the plan of care to improve sleep patterns?

Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

A provider has written an order for a medication drip to be started at 12 units/kg/hour. Your client weighs 297 Ibs. The medication is supplied as 25,000 units in 500 ml. At what rate would you set your pump?

Which action will prevent spreading organisms from one eye to the other when bathing a client?

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

A nurse is performing a health history. What communication techniques should the nurse use? Select all that apply.

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?