The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. What is one of the easiest ways to prevent a pressure ulcer from occurring in an im-mobile client?
a. Keep the skin dry.
b. Provide range-of-motion exercises every shift.
c. Use lift equipment when transferring a client.
d. Turn the client a minimum of every two hours.
D
Implementing a comprehensive skin care program can prevent skin breakdown in all clients, from neonates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turning the client at least every two hours).
Keeping the skin dry is very important in preventing skin breakdown, but turning the client will best help prevent pressure ulcers.
Range-of-motion exercises will help prevent contractures from occurring, but turning the client will best help prevent pressure ulcers.
Lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.
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The purpose of the nursing diagnosis is to:
1. Describe disease and pathology. 2. Delegate nursing interventions. 3. Design nursing activities. 4. Direct the formation of client goals and expected outcomes.
A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.)
a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them in bed. c. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used for transfers.
The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?
A) The patient takes a beta blocker for the treatment of hypertension. B) The patient is under significant psychosocial stress. C) The patient had a pulmonary embolism 18 months ago. D) The patient has a family history of breast cancer.
A patient, age 65, underwent a right hemicolectomy. On postoperative day 4, her surgical wound dehisced. This means that
a. there is partial or complete wound separation. b. there has been inadequate wound closure. c. abdominal viscera protrude through the walls. d. the wound will not heal well when it is resutured.