The nurse admits the client to the surgical unit and determines that the client's Braden scale score is 18. Which does the nurse include in the client's initial plan of care?
1. Use moisturizing lotion to massage the sacrum.
2. Assist client to turn and reposition every 4 hours.
3. Keep the skin clean and dry with frequent bathing.
4. Maintain head of bed at approximately 30 degrees.
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4. The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the client sits in Fowler's or semi-Fowler's position, the lower back and buttocks receive excessive force from the client's weight pressing into the mattress. This in-creases the client's risk of skin breakdown.
1. Moisturizing lotion applied to areas at risk for friction is indicated for any client in bed. The nurse avoids massaging skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and to provide oxygenated blood. The nurse can apply moisturizing lotion to the area without massage.
2. Although the client has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation.
3. Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The nurse keeps the skin clean and dry with daily and as needed bathing using mild soap or commercial bathing products.
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Order: Heparin 8,000 units subcut q8h The route of administration in this order is _______________
a. Soluset b. Sublingual c. Subcutaneous d. Hour of sleep
The nurse is caring for an older client with heart disease that is experiencing fatigue. Which will the nurse initially implement to enhance the overall quality of life and functional ability of the client?
1. Assess the need for assistive devices 2. Provide education on health screenings 3. Reinforce the importance of rehabilitation 4. Instruct the client on techniques for self-management
A client is hospitalized for chemotherapy following a mastectomy for stage IV breast cancer. What should the nurse recognize about the client's cancer?
a. It involved the proximal lymph nodes. b. It involved the distal lymph nodes. c. It had metastasized prior to surgery. d. It was larger than 5 centimeters in diameter.
The parents learn that their newborn has the CFTR gene located on chromosome 7. During counseling, what should the parents be instructed about the way that this genetic alteration may be expressed as the child grows? Select all that apply.
A. The patient is counseled about the increased risk of developing Alzheimer disease. B. The child develops normally without any clinical manifestations associated with cystic fibrosis. C. The patient receives bilateral mastectomies. D. The patient is placed on a lung transplant list. E. The child exhibits some mild signs and symptoms associated with cystic fibrosis.