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A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
- A. Nutritional intake and serum albumin levels
- B. Pressure ulcer diameter and depth
- C. Wound drainage, including color, odor, and consistency
- D. Dressing site and antibiotic ointment application
Correct Answer: A
Rationale: Assessing nutritional intake and serum albumin levels helps determine the client's nutritional status, which is critical for preventing pressure ulcers, as poor nutrition can impair skin integrity. The other options focus on treating existing pressure ulcers rather than preventing their formation.
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A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
- A. Splint the joint and continue passive range of motion to the shoulder only.
- B. A passive range of motion to the right elbow and the right knee back to the right.
- C. Apply weights to the right distal extremity before initiating any joint exercise.
- D. Continue to move the joint only to the point at which resistance is met.
Correct Answer: D
Rationale: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance to prevent injury. Splinting the joint will not assist the client's range of motion and may restrict it further. The option of passive range of motion to the elbow and knee is unclear and not a standard practice. Applying weights to the extremity will not increase range of motion and could cause harm.
A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- A. Place pillows under the client's heels.
- B. Have the client do wheelchair push-ups.
- C. Perform wound care as prescribed.
- D. Massage the client's calves and feet with lotion.
Correct Answer: B
Rationale: Clients who are wheelchair-bound should perform wheelchair push-ups for at least 10 seconds every hour to relieve pressure on weight-bearing areas, reducing the risk of skin breakdown. Pillows under the heels may increase pressure, wound care treats existing ulcers, and massaging the calves in clients with decreased mobility risks embolization.
A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?
- A. 3,5,1,2,4,6
- B. 3,5,2,4,1,6
- C. 3,5,1,2,4,6
- D. 3,5,4,1,2,6
Correct Answer: C
Rationale: The correct sequence for gait training with a cane for a client with left-sided weakness is: (3) Guide the client to a standing position, (5) Place the cane in the client's right hand (strong side), (1) Position for left and around the client's waist for support, (2) Move the cane and left leg forward at the same time, (4) Move the right leg and step forward, (6) Check balance and repeat the sequence. This ensures safe and effective ambulation.
A nurse teaches a client about performing intermittent self-catheterization. The client states, 'I am not sure if I will be able to afford these catheters.' How should the nurse respond?
- A. You may qualify for financial assistance; let's discuss options with a social worker.
- B. Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.
- C. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.
- D. You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.
Correct Answer: D
Rationale: Using clean technique for intermittent self-catheterization at home is sufficient to prevent urinary tract infections and reduces costs by allowing catheter reuse after proper cleaning. Referring to a social worker for financial concerns is appropriate but not the most direct response to the client's concern. Boiling catheters is not a recommended practice, and emphasizing the cost of infections may cause anxiety without addressing the issue.