A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care? 

a) Having the client shift his or her weight every hour
b) Massaging any reddened areas of the skin
c) Placing the client in a semi-reclining position
d) Lubricating the skin with a non-irritating lotion

Answer: D

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

a) 45 degree flexion
b) 15 degree flexion
c) 25 degree flexion
d) 0 degree flexion

Answer: C

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

a) toilet incontinence.
b) reflex (neurogenic) incontinence.
c) functional incontinence.
d) stress incontinence.

Answer: B

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension?

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension? 

a) Nausea
b) Flushing
c) Dry skin
d) Bradycardia

Answer: A

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first?

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first? 

a) Place the cane on the lower step.
b) Step down with the affected leg.
c) Step down with the unaffected leg.
d) Place cane and affected leg on step simultaneously.

Answer: C

Which intervention has the highest priority when providing skin care to a bedridden client?

Which intervention has the highest priority when providing skin care to a bedridden client?

a) Changing the client's position frequently
b) Keeping the skin clean and dry without using harsh soaps
c) Rubbing moisturizing lotion over the pressure areas
d) Gently massaging the skin around the pressure areas

Answer: B