Which of the following clients has the greatest risk for friction-induced skin breakdown?
1. A client who is obese and is frequently incontinent of both urine and feces
2. A client who insists she is comfortable only when positioned on her left side
3. A client who is cognitively impaired and comforts herself by wringing her hands
4. An immobile client who slides down in the recliner where he spends the morning hours
ANS: 3
A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown.
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A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
A) Urinary output of 20 mL per hour B) Respiratory rate of 10 breaths/minute C) Deep tendons reflexes 2+ D) Difficulty in arousing
Staff members have agreed to implement evidence-based practice; they have chosen a specific problem and searched the literature. The group has selected the interventions that seem the easiest to implement
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Healthy People 2020 have targeted injury and violence prevention as a priority. What does the injury prevention objectives of Healthy People 2020 include?
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A client scheduled to have a urea breath test asks the nurse what the purpose of the test is. What should the nurse explain?
1. "It detects the presence of bacteria that contribute to formation of peptic ulcer disease." 2. "It identifies the pressure of the esophageal sphincter." 3. "It is done to determine the amount of hydrochloric acid secreted by your stomach." 4. "It measures the acidity of your esophagus and gastric fluids."