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 client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

Correct answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

3. Which of the following techniques should be used to insert an indwelling urinary catheter for a female client?

Correct answer: D

Rationale: Lubricating the catheter tip before insertion is crucial for female urinary catheterization. This step helps reduce discomfort for the patient and facilitates smooth catheter insertion into the urethra. Using sterile technique maintains asepsis during the procedure, inserting the catheter 2-3 inches ensures proper placement, and inflating the balloon after insertion secures the catheter in place without causing trauma. Proper technique is fundamental for patient comfort, preventing infection, and ensuring the success of the catheterization procedure.

4. A client has a new diagnosis of hypothyroidism, and a nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?

Correct answer: A

Rationale: In hypothyroidism, increasing intake of iodine-rich foods is beneficial as iodine is essential for the production of thyroid hormones. This helps to support thyroid function in individuals with hypothyroidism. Therefore, advising the client to increase their intake of iodine-rich foods aligns with the recommended dietary management for hypothyroidism. Choice B is incorrect because decreasing iodine-rich foods could lead to further deficiency in individuals with hypothyroidism. Choice C is not directly related to hypothyroidism and lactose intolerance is a separate issue. Choice D is incorrect as increasing dairy products is not a specific recommendation for hypothyroidism unless the client has a deficiency of calcium or vitamin D, which should be assessed separately.

5. A healthcare professional is preparing to insert an IV catheter for an older adult client. Which of the following actions should the professional take?

Correct answer: C

Rationale: Placing the client’s arm in a dependent position is the correct action when preparing to insert an IV catheter in an older adult client. This position helps dilate the veins naturally by using gravity, making it easier to locate and access suitable veins for the IV catheter insertion. By positioning the arm in a dependent position, the healthcare professional can take advantage of gravity to increase venous distention, aiding in successful IV catheter insertion.

Similar Questions

A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?
A client with lactose intolerance is being taught about dietary management by a nurse. Which statement by the client shows an understanding of the teaching?
A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?
A client with hypothyroidism is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?
A client with hypertension is being taught about the DASH diet. Which of the following statements by the client indicates an understanding of the teaching?

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