Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur(select the one that does not apply)?

Correct Answer: C

Rationale: The correct answer is C because discontinuing the use of sustained-release opioids is not appropriate for a patient with metastatic bone cancer of the left femur. This patient likely experiences severe pain that requires opioids for adequate pain management. Monitoring serum calcium levels (A) is essential due to the risk of hypercalcemia. Teaching about the need for strict bed rest (B) helps prevent fractures and reduces pain. Supporting the left leg when repositioning the patient (D) helps maintain alignment and prevent further damage.

Correct Answer: C

Rationale: The correct answer is C: Pulling the client up in bed. This action involves the greatest risk of skin shearing because it creates friction and shear forces on the skin, especially when the client is moved against the surface of the bed. This can lead to skin breakdown and pressure ulcers. Rolling the client from supine to side-lying position (B) and helping the client ambulate after surgery (D) can cause shear forces but to a lesser extent compared to pulling the client up in bed. Inserting a peripheral intravenous catheter (A) does not involve significant shear forces on the skin.

Correct Answer: D

Rationale: The skin's role in homeostasis includes temperature control, making 'thermal regulation by skin blood flow dilation or constriction'. The hypothalamus signals skin vessels to vasoconstrict e.g., conserving heat in cold (temp up 1°C) or vasodilate e.g., shedding heat in warmth (temp down 2°C) per Baranoski and Ayello (2004). , 'synthesis of vitamin K,' is false; skin makes vitamin D via UV e.g., 10 minutes sun yields 1000 IU not K, which liver produces. , 'elimination of carbon dioxide,' is lungs' job e.g., 35-45 mmHg CO2 exhaled, not skin. , 'glucose regulation by Langerhans cells,' misattributes; pancreatic islets, not skin's Langerhans (immune cells), manage glucose e.g., insulin drops 100 mg/dL. Skin's sweat and blood flow e.g., dilating vessels in 90°F heat regulate temp, a nurse's focus in fever or hypothermia. Unlike lungs or pancreas, skin's thermal role is dynamic, immediate, and measurable, aligning with essentials in *Wound Care Essentials*, making the accurate function.

Correct Answer: A

Rationale: A nonblanchable red area on the malleolus is 'Stage 1' , per Potter's *Essentials*. Intact skin with persistent erythema e.g., no lightening after 10 seconds marks early injury, unlike 'Stage 2' , partial-thickness e.g., open blister. 'Stage 3' is full-thickness e.g., fat exposed, not here. 'Stage 4' shows bone e.g., deep loss, not redness. A nurse records e.g., Malleolus red, intact' Stage 1's 60% progression risk, per NPUAP, needing padding. Potter notes Stage 1 as first warning, distinct from Stage 2's dermal breach, a physiological assessment staple. is the correct, initial stage.

Correct Answer: A

Rationale: The primary advantage of a 'hydrogel dressing' is to 'provide moisture needed for wound healing,' per Potter's *Essentials*. Moisture e.g., 90% water keeps granulation alive e.g., heals 50% faster unlike 'absorbent' , gauze's role e.g., drainage, not moisture. 'Negative pressure' is NPWT e.g., vacuums fluid, not hydrogel. 'Protection' fits hydrocolloids e.g., seals, not moistens. A nurse uses e.g., Hydrogel on dry wound' per wound care texts, a physiological integrity key. Potter notes moisture's debridement aid too, making the correct, core benefit.