A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
Patient will turn side to back to side with assistance every 2 hours.
Patient will use the walker correctly to ambulate to the bathroom as needed.
Patient will use a sliding board correctly to transfer to the bedside commode as needed.
The Correct Answer is B
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
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Correct Answer is ["A","B","C","D"]
Explanation
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.
Correct Answer is C
Explanation
A. Discontinuing pain medication may not be appropriate, as it can lead to inadequate pain management for the patient. Pain management is crucial for terminally ill patients.
B. While abdominal massage may help relieve mild constipation, it is not a reliable primary intervention for more severe constipation caused by medication.
C. Laxatives are commonly prescribed for constipation related to pain medication and are an effective method to promote bowel movements, making this the best choice.
D. Administering enemas twice daily can be excessive and may cause discomfort or lead to dependency, making this option less favorable than using laxatives.