The nurse caring for a 78-year-old male client recovering from ...

[NguyenJ]

The nurse caring for a 78-year-old male client recovering from hip replacement surgery is as-sessing for signs of improvement of the client's activity tolerance. The nurse determined a base-line for ongoing assessments by:
 
  1. Determining how much time it takes the client to recover from an activity
  2. Assessing how much the client can do at one time
  3. Determining the level of pain experienced by the client during the activity
  4. Asking the client how much the client feels like doing

Question 2

The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:
 
  1. Keep the skin dry
  2. Provide range of motion every shift
  3. Use lift equipment when transferring a client
  4. Turn the client a minimum of every 2 hours

[Mholman93]

Answer to Question 1

ANS: 1
When the client experiences decreased activity tolerance, carefully assess how much time the client needs to recover. Decreasing recovery time indicates improving activity tolerance. Pain should not be an assessment of activity tolerance. Asking the client how much he feels like doing before an activity will not tell the nurse if he is improving over time. The client may be able to do more (or less) than he thinks he is capable of doing before an activity.

Answer to Question 2

ANS: 4
Implement a comprehensive skin care program to prevent skin breakdown in all clients, from ne-onates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.

[NguyenJ]

TYSM

[Mochi]

Excellent