a nurse is planning care for a client who has a pressure ulcer which of the following interventions should the nurse include in the plan
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

2. What action should the healthcare provider take for a patient with a chest tube?

Correct answer: D

Rationale: Ensuring the water seal chamber is filled to the prescribed level is essential for the chest tube's effective functioning. This maintains the integrity of the system, prevents air from entering the pleural space, and facilitates proper drainage. Stripping the drainage tubing, keeping the drainage system below the chest level, or clamping the chest tube during ambulation are not recommended practices and can lead to complications.

3. What is the primary goal of palliative care?

Correct answer: C

Rationale: The primary goal of palliative care is to provide comfort and improve the quality of life for clients with serious illnesses. Palliative care aims to address physical, emotional, and spiritual needs to enhance overall well-being rather than focusing on curing the underlying illness, prolonging life, or preparing for surgery. It emphasizes symptom management, pain relief, and support for patients and their families to ensure a better quality of life during the course of their illness.

4. 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?

Correct answer: C

Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.

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

Correct answer: B

Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.

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