A client has the nursing diagnosis Risk for Impaired Skin ...

[appyboo]

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem?
 
  1. Encourage the 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

A client needs to have soft contact lenses removed. What should the nurse do when removing the lenses?
 
  1. Gently pinch the lens and lift it out.
  2. Have the client look up.
  3. Pull the lower eyelid upward.
  4. Use the pad of the ring finger.

[T4T]

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: 1
Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps for removing a client's soft contact lenses.
Rationale 2: The nurse should have the client look straight ahead, not up.
Rationale 3: The upper eyelid is pulled down gently.
Rationale 4: The nurse would use the pad of the index finger, not the ring finger.

[appyboo]

Excellent

[scottmt]

Thanks for the timely response, appreciate it