A client with dementia and severe pruritis is receiving intravenous steroids and is constantly scratching the skin. What intervention is best for the client at this time?
1. Placing four side rails in the up position
2. Application of hand mitts
3. Application of four-point leather restraints
4. Application of a falls risk bracelet
Correct Answer: 2
Rationale 1: Raising the four side rails will not help with the itching skin.
Rationale 2: Applying hand mitts will protect the skin from breakdown secondary to scratching of the skin. The client is at risk for infection from the steroid medication, so the nurse should make every attempt to keep the client's skin clean, dry, and intact.
Rationale 3: Four-point leather restraints will not help with the itching skin.
Rationale 4: The client might be at risk for falls; however, this is not the priority intervention at this time.
Global Rationale: Applying hand mitts will protect the skin from breakdown secondary to scratching of the skin. The client is at risk for infection from the steroid medication, so the nurse should make every attempt to keep the client's skin clean, dry, and intact. Putting side rails up, using leather restraints, and application of risk for falls bracelet will not prevent infection.
You might also like to view...
Order: Heparin 25,000 units in 1000 mL 0.09% NS, infuse at 100 mL/h. Calculate the units per day if the dose is within the normal daily range (20,000–40,000 units in 24 h)
1. 60,000 units, which is within the normal daily range 2. 2500 units, which is not within the normal daily range 3. 25,000 units, which is within the normal daily range 4. 60,000 units, which is not within the normal daily range
When documenting in a patient's chart, the nurse should:
a. include speculation. b. chart consecutively. c. leave blank spaces. d. include retaliatory comments.
The client with AIDS and a CD4+ count of 100 cells/mm3 is admitted with a compound fracture of the left leg. In addition, the client has a productive cough, fever, chills, and a his-tory of night sweats. The client's PPD test is negative
What is the nurse's best action? A. Use standard precautions alone because the client does not have tuberculosis. B. Use airborne precautions alone because the client is taking appropriate therapy for HIV. C. Use standard precautions and airborne precautions because the client has tuber-culosis. D. Use standard precautions and airborne precautions until a chest x-ray shows the client does not have tuberculosis.
A nurse realizes a patient has thrombocytopenia when the platelet count is below _____ platelets per cubic millimeter
Fill in the blank(s) with the appropriate word(s).