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 is receiving discharge teaching after a total hip arthroplasty. Which of the following instructions should be included?

Correct answer: B

Rationale: To prevent dislocation of the hip prosthesis, the client should avoid bending their hips more than 90 degrees. Excessive bending at the hips can increase the risk of hip dislocation, which is a significant concern following total hip arthroplasty. Sitting with crossed legs at the ankles (choice A) can also increase the risk of hip dislocation and should be avoided. Sitting in a low-seated chair (choice C) can make it more challenging for the client to stand up safely. Twisting the body when standing up (choice D) can also strain the hip joint and increase the risk of dislocation. Therefore, the correct instruction to include during discharge teaching is to avoid bending the hips more than 90 degrees.

3. A client with celiac disease is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A: 'I should avoid foods that contain gluten.' Celiac disease requires the avoidance of gluten-containing foods to manage symptoms and prevent complications. Gluten is found in wheat, barley, and rye. Choices B, C, and D are incorrect as they do not align with the dietary requirements for managing celiac disease. Increasing intake of foods high in gluten or lactose would be detrimental for someone with celiac disease.

4. When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?

Correct answer: D

Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.

5. A client has a new diagnosis of renal calculi, and the nurse is teaching about dietary management. Which of the following statements should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is to decrease the intake of calcium-rich foods when managing renal calculi. Calcium can contribute to the formation of stones in the kidneys, so reducing its intake can help prevent the development of new calculi and manage existing ones.

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