Which nursing intervention should be applied to a client with a ...

[pane00]

Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity Impairment related to immobility?
 
  1. Encourage client to eat at least 40 of meals.
  2. Keep linens dry and wrinkle-free.
  3. Restrict fluid intake.
  4. Turn client every 3 hours.

Question 2

What should the nurse include as foot care for the client who is newly diagnosed with diabetes?
 
  1. Cut toenails around and file.
  2. Dry toes thoroughly.
  3. Wash feet with water at a temperature of 90F to 98.6F.
  4. Inspect feet thoroughly once a week.

[bassamabas]

Answer to Question 1

Correct Answer: 2
Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40 of their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.

Answer to Question 2

Correct Answer: 2
Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients' toenails. Only a podiatrist should handle this task.
Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration.
Rationale 3: The water to wash the feet should be 100F to 110F.
Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems.

[pane00]

Excellent

[sultansheikh]

TYSM