A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

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Question 1 of 5

A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

Correct Answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

Question 2 of 5

A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

Correct Answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

Question 3 of 5

A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

Correct Answer: A

Rationale: Corrected Rationale: The nurse should instruct the client to use pursed-lip breathing during activities to help improve oxygenation. Pursed-lip breathing can keep the airways open longer, facilitating better oxygen exchange and making it easier to exhale carbon dioxide. Choice B is incorrect as physical activity, within the client's limitations, is beneficial for maintaining overall health. Choice C is incorrect as weight-bearing exercises are important for bone health but not directly related to improving oxygenation in COPD. Choice D is incorrect as using a humidifier while sleeping can help with moisture in the airways but does not directly impact oxygenation in COPD.

Question 4 of 5

A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?

Correct Answer: B

Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.

Question 5 of 5

A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?

Correct Answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.

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