Share This Link

Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

Elevate the head of the client's bed 45°:Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.

Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.

Provide the client with a high-calorie diet:While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.

Bradycardia: Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.

Flushed skin: Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x

Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.

Metoprolol 50 mg PO daily:This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.

Maintain accurate intake and output records:Monitoring intake and output is important in managing fluid balance.However, in this situation, the priority is to address the existing fluid overload promptly.

Encourage fluid intake, more than 2000 mL/day:In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.

A slightly elevated heart rate (tachycardia) could occur in response to fluid shifts or the underlying condition, but it is not a specific indicator of an adverse outcome related to hypertonic saline infusion.

Sediment or blood in the urine is not a typical adverse outcome associated with hypertonic saline infusion. These findings may indicate a separate issue, such as a urinary tract infection or renal impairment, but they are unrelated to the administration of 3% saline for hyponatremia.

A rise in blood pressure may be expected as a result of volume expansion due to fluid administration, and it may even be beneficial if the patient was hypotensive.

Hypocalcemia:Hypocalcemia is not typically associated with MCNS. In fact, the loss of proteins, including albumin, in the urine can lead to decreased oncotic pressure in the blood vessels, resulting in edema. However, calcium levels are usually within the normal range.

Hyperalbuminemia:
This is not a characteristic finding in minimal change nephrotic syndrome. In fact, the condition is associated with hypoalbuminemia due to the loss of albumin in the urine.

Positive for Ketones:Ketones are not typically associated with minimal change nephrotic syndrome. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or starvation.

Apply Neosporin to avoid infection:This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.

Apply elbow immobilizers when not being held:This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.

Feed increased amounts of formula to prevent weight loss:While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.

"I will allow the position my mother finds most comfortable during the feeding."This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

"I will turn my mother on her left side during the feeding."Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

"I will elevate the head of the bed 10 degrees during the feeding."While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

Memory lossMemory loss is not typically associated with an inadequate dietary intake of fiber. It is more commonly related to other factors such as aging, medical conditions, or nutritional deficiencies.

Brittle hair
Brittle hair is not a direct result of an inadequate intake of dietary fiber. Hair health is influenced by various factors, including overall nutrition and hydration.

Bleeding gumsBleeding gums are not directly linked to an inadequate intake of fiber. However, insufficient vitamin C intake, which is often found in fruits and vegetables (sources of fiber), can contribute to gum problems.