The nurse is caring for a bedridden client. Which intervention will the nurse implement to prevent pressure ulcer formation?
a. Adjust nutritional intake based on serum albumin levels.
b. Measure the ulcer diameter and depth every shift.
c. Change the gauze dressing whenever drainage is observed.
d. Apply antibiotic ointment to all excoriated skin areas.
A
Assessing serum albumin levels helps determine the client's nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.
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The student nurse learns that the most important function of inflammation and immunity is which purpose?
a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance
The nurse teaches parents that the severity of infant respiratory distress syndrome (RDS) is most influenced by:
a. poor cough and gag reflex. b. the gestational age at birth. c. administering high concentrations of oxygen. d. the sex of the infant.
A client asks why the intravenous fluid contains glucose. What should the nurse respond to this client?
a. "It is easily digested." b. "It will help you feel better faster." c. "Glucose is an energy source for the body." d. "Glucose aids in the prevention of dehydration."
The nurse teaches a class on reproduction for adolescents and explains that which female reproductive organs engorge and become sensitive during stimulation? Select all that apply
a. Vagina b. Labia majora c. Labia minora d. Clitoris e. Bartholin's glands