In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?

Correct Answer: B

Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers. Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning. Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning. Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.

Correct Answer: C

Rationale: The correct answer is C: Bureau of Vital Statistics. The Bureau of Vital Statistics is responsible for maintaining records on births, deaths, and other vital events in a particular region. Therefore, it is the most likely state resource to provide information on infant death rates. Disease registry (A) typically focuses on specific diseases rather than overall mortality rates. Department of Health (B) may have some data but may not specifically focus on vital statistics. Census data (D) provides population demographics but does not specifically track infant death rates.

Correct Answer: B

Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.

Correct Answer: D

Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake. Rationale: 1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects. 2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms. 3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety. Summary: A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety. B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it. C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.

Correct Answer: C

Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult. A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony. B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage. D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.