A nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. What is the nurse's best action?
A. Rub the areas with an oil-based lubricant.
B. Perform hip flexion and extension ROM exercises.
C. Reposition the client so that the reddened area does not bear weight.
D. Ensure that the client sits in a chair at least once each shift.
C
The reddened areas should not be rubbed, because this action could cause more extensive dam-age to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnera-ble to breakdown. Appropriate interventions to relieve the pressure on these areas through posi-tioning, assistive devices, and skin protection interventions should then be used.
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a. Beyond the legal scope of the practical nurse b. The use of personal values and beliefs to solve problems c. Unnecessary if there are comprehensive physician orders d. Governed by the law
A care modality is a:
a. method of organizing and delivering nursing care. b. staffing grid that outlines nursing unit work schedules. c. place or unit in which care is delivered. d. unit that specializes in caring for a specific population.
The nurse observes ashen-colored lips and tongue on the client with dark skin. Which does the nurse want to rule out by using a focused assessment?
1. Jaundice 2. Cyanosis 3. Erythema 4. Hypoxemia
Nurses with varying levels of experience possess leadership skills. A graduate nurse walks out of the nurse manager's office after a meeting
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