Which intervention is important in preventing pressure ulcers in immobilized patients?

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Question 1 of 5

Which intervention is important in preventing pressure ulcers in immobilized patients?

Correct Answer: A

Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.

Question 2 of 5

A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?

Correct Answer: D

Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.

Question 3 of 5

The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?

Correct Answer: C

Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.

Question 4 of 5

The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?

Correct Answer: A

Rationale: Removing the nasal cannula during oral care (A) allows thorough hygiene without interference, briefly tolerable given short duration. Increasing flow (B) is unnecessary. Petroleum jelly (C) isn't for oral care. Mouth breathing (D) isn't needed if removed. Removal, per nursing practice, ensures effective care.

Question 5 of 5

Which of the following findings is associated with right-sided heart failure?

Correct Answer: B

Rationale: Nocturnal polyuria is linked to right-sided heart failure, where fluid shifts from edematous tissues to the bloodstream at night, increasing urine output as the heart struggles to pump against venous congestion. Shortness of breath and crackles typify left-sided failure, while daytime oliguria isn't specific. Nurses monitor this to assess heart function, guiding fluid management and diuretic use effectively.

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