Author Question: A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle ... (Read 39 times)

Frost2351 · **on:** Jun 25, 2018

A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?

A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.

Question 2

A nurse is caring for a premature infant with a central line. The infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status?

A) Hyperbilirubinemia
B) Bacterial sepsis
C) Hypoglycemia
D) Intracranial hemorrhage

b614102004 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: C

Assisting the client to turn at least every 2 hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. Turning the client every 8 hours will not reduce the risk of integumentary complications. Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications.

Answer to Question 2

Answer: B

The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a central line in place who had previously been growing and doing well is suggestive of bacterial sepsis rather than hyperbilirubinemia, hypoglycemia, or intracranial hemorrhage.