While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Avoid friction when sliding up in bed.

Offer supplemental nutritional snacks.

Change bed pads to keep skin clean and dry.

Change position frequently from right to left.

Answer and Explanation

The Correct Answer is D

A.   While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B.   Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C.   While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D.   The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is a critical first step when a medication dose discrepancy is identified. Reporting the mismatch alerts the appropriate personnel (such as the pharmacy or healthcare provider) to investigate and resolve the issue. This ensures that the correct dose is administered and helps prevent potential medication errors.
B. While calculating the dose on hand is important to ensure accurate dosing, this action should be secondary to reporting the issue first. Calculating the dose is part of the process to verify and adjust the dose if needed, but the primary concern is to report the discrepancy to get it addressed properly and safely.
C. Asking the pharmacist for a different dose is a valid action, but it should come after reporting the discrepancy. The pharmacist can provide guidance on whether a different dose can be dispensed and help clarify any issues with the medication.
D. Withholding the medication is an appropriate precaution if there is uncertainty about the dose, but it is not the first action to take. This step should follow the initial reporting of the discrepancy to ensure that the medication is correct and safe to administer.

A. Record the client's ability to perform ADLs safely. B. Initiate a fall risk protocol for the client. C. Teach the client to shorten the stride to prevent falls. D. Determine the client's activity tolerance.

Correct Answer is A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

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?