a nurse is planning care for a client who has a pressure ulcer which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?

Correct answer: D

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.

2. A healthcare professional is educating a client with osteoporosis about dietary management. Which of the following foods should the professional recommend?

Correct answer: B

Rationale: Fortified cereal is the correct answer as it is an excellent choice for individuals with osteoporosis due to its high calcium and vitamin D content, both essential nutrients for bone health. These nutrients help in maintaining bone density and strength, which is crucial for individuals with osteoporosis. Green beans (choice A) do not provide as much calcium and vitamin D as fortified cereal. Red meat (choice C) is a good source of protein but is not as rich in calcium and vitamin D compared to fortified cereal. White bread (choice D) lacks the essential nutrients needed for bone health, making it a less suitable choice for individuals with osteoporosis.

3. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

4. A client has a new prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

Correct answer: C

Rationale: Fresh fruits are naturally low in sodium, making them a suitable choice for a low-sodium diet. They provide essential nutrients and are a healthy option for individuals who need to limit their sodium intake. Pickles (Choice A) and canned soup (Choice B) are typically high in sodium and should be avoided in a low-sodium diet. Smoked salmon (Choice D) is also usually high in sodium due to the smoking process, so it is not a recommended choice for a low-sodium diet.

5. A client with a new diagnosis of hypothyroidism is being taught about medication management. Which of the following statements should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'You should take your medication on an empty stomach.' When educating a client with hypothyroidism, it is essential to advise taking thyroid medication on an empty stomach to enhance absorption and effectiveness. Taking the medication with food, especially high-fiber or with supplements like calcium, can interfere with absorption and reduce its efficacy. Therefore, it is crucial for the client to follow the recommendation of taking the medication on an empty stomach. Choices A, C, and D are incorrect because taking the medication with a high-fiber meal (Choice A) or with a calcium supplement (Choice C) can hinder absorption, and taking it before bedtime (Choice D) does not optimize absorption compared to taking it on an empty stomach.

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