Basic Care and Comfort Rationale

1 C: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when
turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow
to areas of potential injury is maintained.

2 A: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or
intestine rather than in the airways.

3 B: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly
processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.

4 B: Decreased sodium and potassium. Children with AGN who have edema, hypertension oliguria, and azotemia
have dietary restrictions limiting sodium, potassium, fluids, and protein.

5 D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables
and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.

6 B: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces
around the obstruction. This is often mistaken for uncontrolled diarrhea.

7 D: baked potato. A baked potato contains 610 milligrams of potassium.

8 B: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption.
However, initial feedings may be given by bolus to assess the client''s tolerance to formula.

9 B: Check the client’s gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable
nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally
the lung. A loss or an impairment of the protective cough reflex can result in aspiration.

10 A: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in
fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. There is no
evidence that pain of older adults is less intense than younger adults. It is important for the nurse to assess the pain
thoroughly before implementing pain relief measures.

11 C: Perform frequent oral care with a tooth sponge. Frequent cleansing and stimulation of the mucous membrane is
important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or
mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only
moisturize.

12 A: exercise doing weight bearing activities. Weight bearing exercises are beneficial in the treatment of
osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client
includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment
protocol.

13 A: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and
surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due
in part to poor hydration and inadequate protein intake.

14 B: obtain a health and dietary history. Initially, the nurse should obtain information about the chronicity of and
details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity
pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment
plan.

15 D: It is no longer advisable to use only the lower side rails. Using all 4 side rails (upper and lower siderails at the
top and bottom of the bed) is an inappropriate use of restraint without an order. If all 4 are pulled up, an order for
protective restraints is needed that usually has to be renewed in 48 to 72 hours along with more frequent
documentation. Having all 4 side rails raised limits the client’s autonomy and freedom of movement. Using 3 of the 4
side rails pulled up is acceptable, because clients can safely exit the bed on their own initiative. Placing the bed
against the wall permits getting out of bed on only 1 side. Locking the wheels keeps the bed from sliding. Keeping the
bed in the lowest position (without bending limbs to restrict movement) provides a shorter distance to the ground if
the client chooses to get out of bed.

16 C: laxatives. Some elders are constipated because they have used over-the-counter laxatives for a long time. In addition, many
people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications, including opioid analgesics, are
constipating. Elders are rarely constipated because of organic or pathological reasons.

17 B: Immobility in children has similar physical effects to those found in adults. Care of the immobile child includes
efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone
demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar
effects and alterations occur in adults.

18 A: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal
tract.

19 C: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from
enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on
heparin.

20 C: accept the client’s report of pain. Although all of the options above are correct, the first and most important
piece of information in this client’s pain assessment is what the client is telling you about the pain --“the client’s
report.”