1. A customer who has a pressure-relieving bed overlay is mobilized to a chair and imprints
of the patron's buttocks, heels, and scapula are evident on the bed overlay. What action
should the sensible nurse implement? - ANS-Apply a distinctive pressure-relieving
device and investigate its effectiveness for this customer.
2. Rationale
3. The deeper the indent or imprint of the body left inside the bed, the more compressed,
the tougher the floor, and the less supportive it's far for the client. Bottoming out, as
evidenced through the deep imprints within the bed overlay, shows that this device isn't
indicated for this customer and a one-of-a-kind device or strategy must be implemented
to save you stress ulcer formation.
4. A customer whose food plan is low in fiber is at danger for which situation? - ANS-Colon
most cancers.
5. Rationale
6. Fiber speeds the motion of substances via the GI tract, lowering the quantity of time the
colon absorbs water and its exposure to digestive give up-merchandise that may be
carcinogenic. Low-fiber diets boom the chance for constipation and colon most cancers.
7. An older male purchaser tells the realistic nurse (PN) that his faith does not permit him to
bathe daily. How must the PN respond? - ANS-Request that the patron make clear his
religious ideals about bathing.
8. Rationale
9. A consumer's non secular and cultural options must be considered while offering simple
hygiene. The purchaser's spiritual ideals should be considered inside the purchaser's
preference so collecting in addition statistics about the purchaser's self care practices is
essential.
10. The sensible nurse (PN) identifies several findings in an older client who is on extended
bed rest. Which finding requires prompt motion by using the PN? - ANS-Bowel moves
lower to one each 0.33 day.
11. Rationale
12. Immobility reduces venous go back, appetite, fluid consumption, and peristalsis, which
reduces the frequency of bowel actions and increases the chance for constipation and
impaction, which requires set off intervention.
13. The sensible nurse (PN) is obtaining the important signs for a purchaser who has a
urinary tract infection with methicillin-resistant Staphylococcus aureus (MRSA). How
have to the PN proceed? - ANS-Don a gown and gloves earlier than coming into the
room.
14. Rationale
15. MRSA within the urinary tract calls for contact isolation, which incorporates using a gown
and gloves. In addition to gloves and a disposable stethoscope, a gown must be worn to
avoid potential contact with MRSA-infected environmental surfaces while taking vital
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