The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?
Reposition the client at least every two hours.
Encourage the client to limit fluid intake.
Use a donut-shaped cushion under the client's hips.
Apply a heating pad to the client's back every four hours
The Correct Answer is A
A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.
B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.
C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.
D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.
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Correct Answer is C
Explanation
A. Initiation of a high-sodium diet. A high-sodium diet is not indicated in pulmonary embolism management; it could worsen fluid retention and cardiovascular strain.
B. Application of a cast to the affected limb. Casting is not appropriate for pulmonary embolism, as it is not an orthopedic injury. Immobilization could increase the risk of further clot formation.
C. Administration of anticoagulant therapy. Anticoagulant therapy, such as heparin or warfarin, is the primary treatment for pulmonary embolism to prevent further clot formation and allow the body to dissolve the clot.
D. Administration of bronchodilators. Bronchodilators may alleviate respiratory symptoms but do not treat the underlying clot in pulmonary embolism. Anticoagulation remains the primary treatment.
Correct Answer is A
Explanation
A. "I understand that CAD is caused by the buildup of fat deposits in my arteries." CAD is caused by the accumulation of plaque (cholesterol, fats, and other substances) within the coronary arteries, which restricts blood flow to the heart muscle.
B. "Only people with a family history of heart disease are at risk for CAD." Although a family history can increase risk, many other factors, like high blood pressure, smoking, high cholesterol, and lifestyle, contribute to CAD risk.
C. "CAD can be completely cured with a healthy diet and exercise." While lifestyle changes can significantly reduce the progression of CAD and improve symptoms, they do not cure the disease.
D. "I should avoid all physical activity to prevent worsening my CAD." Physical activity, when performed safely and under medical guidance, is beneficial for CAD management and can help improve cardiovascular health.