Author Question: The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and ... (Read 69 times)

ENagel · **on:** Jul 22, 2018

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete?

a. Encourage the patient to sit up in the chair.
b. Provide analgesic medication as ordered.
c. Explain the risks of immobility to the patient.
d. Turn the patient every 3 hours while in bed.

Question 2

An 84-year-old diabetic patient is admitted for insulin regulation.

Which of the following sets of blood pressure (mm Hg), pulse (beats per minute), and respiration (breaths per minute) measurements, respectively, is considered to be within the expected limits for a patient of this age? a. Blood pressure 138/88, pulse 68, respirations 16
b. Blood pressure 94/52, pulse 68, respirations 30
c. Blood pressure 108/80, pulse 112, respirations 15
d. Blood pressure 132/74, pulse 90, respirations 24

tjayeee · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.

Answer to Question 2

A

Feedback
A The measurements, Blood pressure 138/88, pulse 68, respirations 16, are within the expected limits for an older adult patient. An adult's average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an older adult's pulse is 60 to 100 beats per minute. The expected respiratory rate is 16 to 25 breaths per minute.
B The values, Blood pressure 94/52, pulse 68, respirations 30, are not within the expected limits for a patient of this age.
C The values, Blood pressure 108/80, pulse 112, respirations 15, are not within the expected limits for a patient of this age.
D The values, Blood pressure 132/74, pulse 90, respirations 24, are not within the expected limits for a patient of this age.