Author Question: A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ... (Read 83 times)

crobinson2013 · **on:** Jun 25, 2018

A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?

a. Nutritional intake and serum albumin levels
b. Pressure ulcer diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application

Question 2

A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?

a. Splint the joint and continue passive range of motion to the shoulder only.
b. Progressively increase joint motion 5 degrees beyond resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Continue to move the joint only to the point at which resistance is met.

izzat · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Assessing serum albumin levels helps determine the client's nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.

Answer to Question 2

ANS: D
Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance. Splinting the joint will not assist the client's range of motion. The client's joint should not be forced. Applying weights to the extremity will not increase range of motion of the joint but most likely will cause damage.