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. A client has a new prescription for a low-fat diet. Which of the following foods should be recommended?

Correct answer: C

Rationale: When following a low-fat diet, it is essential to choose foods that are low in fat. Chicken breast is a lean protein source that is low in fat, making it a suitable option for a low-fat diet. Bacon, whole milk, and cheese are higher in fat content and should be avoided or limited in a low-fat diet. Bacon is high in saturated fat, whole milk contains significant amounts of fat, including saturated fat, and cheese is also high in fat. Therefore, these options are not ideal for a low-fat diet.

3. A healthcare provider is caring for a client who has acute renal failure. Which of the following laboratory results should the healthcare provider expect?

Correct answer: C

Rationale: In acute renal failure, the kidneys are unable to excrete potassium efficiently, which can lead to hyperkalemia. As a result, an increased potassium level is a common finding in clients with acute renal failure. Hyperkalemia can have serious cardiac effects, making it essential for healthcare providers to monitor and manage potassium levels closely in clients with renal impairment. Choices A, B, and D are incorrect because in acute renal failure, blood urea nitrogen (BUN) and creatinine levels typically rise due to decreased renal function. Calcium levels are more likely to be decreased in acute renal failure due to impaired activation of vitamin D and subsequent decreased calcium absorption.

4. A client with iron-deficiency anemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.

5. During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?

Correct answer: C

Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.

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