An elderly client has been bedridden since a cerebrovascular...

An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?

A. Nutritional status.
B. Urinary incontinence.
C. Episodes of confusion.
D. Right-sided paralysis.

Correct Answer: A

Rationale: Poor nutritional status impairs skin integrity and healing, making it the most critical factor for skin breakdown.

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Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.

A. Warm the fingers or toes by using an electric heating pad
B. Wear warm socks or gloves when exposed to cold temperatures
C. Check the temperature of bath water before entering
D. Use a hot water bottle to warm feet at night
E. Avoid crossing the legs when sitting
F. Use a heating blanket when cold

Correct Answer: B,C,E,G

Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.

The nurse is working in a newborn nursery and caring for several neonates. Precautions that should be taken to prevent an infant abduction include which of the following?

A. Notifying the hospital's security staff about anyone who appears unusual.
B. Taking several neonates to their mothers at the same time.
C. Placing the infant near the doorway of the mother's room.
D. Contacting the hospital's security staff if an exit alarm is triggered.

Correct Answer: A,D

Rationale: Notifying security about suspicious individuals and responding to exit alarms are key to preventing abductions. Taking multiple neonates or placing them near doorways increases risk.

The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.

A. Ask the client to rub lotion over the hands every day after bathing.
B. Encourage physical activity, such as ambulation.
C. Provide frequent contacts for communication and socialization.
D. Provide family education.
E. Encourage involvement of family and friends.

Correct Answer: A,B,C,E

Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?

A. Administer the dose as ordered.
B. Hold the dose and notify the physician.
C. Administer half the prescribed dose.
D. Administer vitamin K as an antidote.

Correct Answer: B

Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.

A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?

A. Apply petroleum jelly around the stoma daily.'
B. Clean the area with alcohol wipes before applying the pouch.'
C. Ensure the skin barrier fits snugly and clean with mild soap.'
D. Change the pouch only once a week.'

Correct Answer: C

Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.