A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

Correct Answer: C

Rationale: In this scenario, option C, elevating the head of the bed to 45 degrees, is the most appropriate intervention for a client at risk for developing pressure ulcers. This position helps reduce pressure on the sacrum and heels, two common sites for pressure ulcers. By elevating the head of the bed, the client's weight is distributed more evenly, decreasing the risk of tissue ischemia and pressure ulcer formation. Option A, using a donut-shaped cushion, is incorrect as it can actually increase pressure on vulnerable areas rather than distributing it evenly. This can exacerbate the risk of pressure ulcers rather than prevent them. Option B, turning the client every 4 hours, is a standard preventive measure for pressure ulcers, but it is not the most appropriate intervention in this specific case. Turning the client alone may not adequately alleviate pressure on specific areas prone to ulcers. Option D, massaging reddened areas, is contraindicated as it can further damage fragile skin and tissues, leading to the development or worsening of pressure ulcers. Educationally, it is important for nurses to understand the principles of pressure ulcer prevention and management. Proper positioning, regular repositioning, skin assessment, and pressure redistribution are key components of preventing pressure ulcers in at-risk individuals. Nurses should also be aware of individualized interventions based on the client's specific risk factors and needs to provide optimal care and prevent complications.

Correct Answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.

Correct Answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.

Correct Answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

Correct Answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.