🔹 When a client is positioned in the lateral (side-lying) position, pressure is concentrated on the bony prominences that are in direct contact with the bed.

🔹 The greater trochanter (hip) is the primary pressure point in the lateral position and is at high risk for pressure injury.

🔹 The dependent shoulder (acromion) is also compressed against the mattress and should be inspected regularly.

🔹 The medial and lateral malleoli (ankles) may rub against each other or the mattress, increasing the risk of skin breakdown if they are not properly padded.

🔹 The nurse should use pillows to cushion between the knees and ankles and to support proper body alignment.

🔹 Frequent repositioning (at least every 2 hours) and regular skin assessments help prevent pressure injuries.

🔹 Clients with limited mobility, poor nutrition, or impaired sensation are at particularly high risk for pressure ulcers.

🔹 Therefore, the greater trochanter, shoulder, and ankles are the priority bony prominences to assess in the lateral position.

❌ Occiput, scapulae, and elbows

🔸 These are major pressure points in the supine (back-lying) position.

🔸 They are not the primary pressure areas when the client is lying on the side.

❌ Ileum, clavicle, and humerus

🔸 These structures are not the primary pressure points assessed in the lateral position.

🔸 The greater trochanter and shoulder are at much greater risk.

❌ Chin, elbow, and anterior thighs

🔸 These areas are more commonly associated with the prone (face-down) position.

🔸 They are not the main pressure points in a lateral position.

✅ Parkinson disease

🔹 Parkinson disease significantly increases the risk for falls because it affects balance, coordination, gait, and muscle control.

🔹 Clients often have shuffling gait, bradykinesia (slow movement), muscle rigidity, and postural instability, making ambulation difficult.

🔹 Tremors and impaired reflexes further increase the likelihood of losing balance.

🔹 Difficulty initiating movement and episodes of freezing can lead to unexpected falls.

🔹 Parkinson disease also affects the ability to quickly correct balance when stumbling.

🔹 Nurses should implement fall precautions, encourage the use of assistive devices, and supervise ambulation.

🔹 Environmental hazards should be minimized to reduce fall risk.

🔹 Therefore, Parkinson disease is a major intrinsic risk factor for falls.

✅ Standing blood pressure

🔹 The client's blood pressure decreases from 128/56 mm Hg (sitting) to 92/40 mm Hg (standing).

🔹 This finding indicates orthostatic (postural) hypotension, a major cause of dizziness and falls.

🔹 Orthostatic hypotension reduces cerebral blood flow when standing, causing lightheadedness or syncope.

🔹 Clients should be instructed to rise slowly from sitting or lying positions.

🔹 The nurse should assess for dizziness before ambulation.

🔹 Orthostatic blood pressure changes are especially concerning in older adults.

🔹 Fall precautions should be implemented immediately.

🔹 Therefore, this finding significantly increases fall risk.

✅ Furosemide

🔹 Furosemide is a loop diuretic that increases urine output and may contribute to falls.

🔹 It can cause orthostatic hypotension, dehydration, dizziness, and electrolyte imbalances, especially hypokalemia.

🔹 Frequent trips to the bathroom also increase the likelihood of falls, particularly in older adults.

🔹 The nurse should monitor blood pressure, hydration status, and electrolyte levels.

🔹 Clients should be encouraged to ask for assistance when ambulating to the bathroom if needed.

🔹 Medication-related falls are common among older adults taking diuretics.

🔹 Timing of medication administration may help reduce nighttime falls.

🔹 Therefore, furosemide is a significant medication-related fall risk.

❌ Temperature

🔸 A temperature of 37.2°C (99°F) is within the expected range and does not increase the client's fall risk.

🔸 There is no evidence of fever or infection contributing to instability.

❌ Respiratory rate

🔸 A respiratory rate of 18/min is within the normal adult range.

🔸 It does not indicate respiratory distress or contribute to an increased risk of falls.

🔹 Healing by primary intention occurs when a clean wound with well-approximated edges is closed using sutures, staples, or adhesive strips.

🔹 Because the wound edges are brought together, there is minimal tissue loss and little space for new tissue to fill.

🔹 Primary intention results in rapid healing, a lower risk of infection, and minimal scar formation.

🔹 Surgical incisions are the most common example of wounds healing by primary intention.

🔹 Little granulation tissue is needed because the wound edges are already approximated.

🔹 Nurses should monitor the incision for signs of infection, dehiscence, and proper approximation of the wound edges.

🔹 Proper wound care and aseptic technique promote uncomplicated healing.

🔹 Therefore, sutured skin edges are the expected finding in a wound healing by primary intention.

❌ Wound is contaminated at the time of injury.

🔸 Contaminated wounds are more likely to heal by secondary or tertiary intention.

🔸 Primary intention involves clean, uncontaminated wounds.

❌ Healing of the wound is prolonged.

🔸 Healing by primary intention is the fastest type of wound healing because the wound edges are closed.

🔸 Prolonged healing is more characteristic of secondary intention.

❌ Granulation tissue is forming at the bottom of the wound bed.

🔸 Extensive granulation tissue is typical of secondary intention, where the wound heals from the bottom up.

🔸 Primary intention requires minimal granulation tissue because the wound edges are already approximated.

74.8 lb × 0.45 = 33.66 kg

Dose ordered:

1.5 mg/kg × 33.66 kg = 50.49 mg

Available:

125 mg / 2 mL = 62.5 mg/mL

mL to give:

50.49 mg ÷ 62.5 mg/mL = 0.807 mL

Rounded to nearest tenth = 0.8 mL

🔹 Healing by secondary intention occurs when a wound has significant tissue loss, and the wound edges cannot be brought together.

🔹 The wound heals from the bottom up through the formation of granulation tissue, which fills the wound defect.

🔹 This type of healing is common in pressure injuries, venous ulcers, diabetic foot ulcers, and traumatic wounds.

🔹 Secondary intention takes longer to heal than primary intention because new tissue must fill the wound before epithelialization occurs.

🔹 These wounds have a greater risk of infection and usually result in more scar formation.

🔹 The nurse should monitor for healthy, beefy-red granulation tissue, which indicates normal healing.

🔹 Proper wound care, nutrition, and infection prevention are essential to promote healing.

🔹 Therefore, granulation tissue filling the wound is the hallmark of healing by secondary intention.

❌ The wound edges are well-approximated.

🔸 Well-approximated wound edges are characteristic of primary intention healing.

🔸 These wounds are usually closed with sutures, staples, or adhesive strips.

❌ The wound is closed at a later date.

🔸 This describes tertiary intention (delayed primary closure).

🔸 The wound is initially left open and later surgically closed after contamination or infection risk has decreased.

❌ A skin graft is placed over the wound bed.

🔸 A skin graft is a treatment option for certain large or complex wounds.

🔸 It is not a defining feature of secondary intention healing.

🔹 The priority when providing oral care to an unconscious client is to maintain a patent airway and prevent aspiration.

🔹 Unconscious clients have decreased or absent gag and cough reflexes, making them unable to protect their airway.

🔹 Saliva, oral secretions, and fluids used during oral care can accumulate in the mouth and be aspirated into the lungs.

🔹 Suctioning the oral cavity as needed removes excess secretions and significantly reduces the risk of aspiration and pneumonia.

🔹 The nurse should position the client in a side-lying (lateral) position whenever possible to facilitate drainage of secretions.

🔹 Oral care should be performed gently while continuously monitoring for signs of airway obstruction.

🔹 Maintaining oral hygiene also decreases bacterial colonization, reducing the risk of ventilator-associated or aspiration pneumonia.

🔹 According to the ABCs (Airway, Breathing, Circulation), airway protection is always the highest priority.

❌ Hold the client's mouth open with gloved fingers.

🔸 The nurse should never place fingers inside an unconscious client's mouth, as this increases the risk of injury if jaw muscles contract.

🔸 A padded oral airway or bite block should be used if necessary.

❌ Use foam swabs to help remove plaque.

🔸 Foam swabs may be used for gentle oral care but do not effectively remove plaque compared with a soft toothbrush.

🔸 More importantly, plaque removal is not the immediate priority over protecting the airway.

❌ Moisten the mouth using lemon-glycerin sponges.

🔸 Lemon-glycerin swabs are not recommended because they can dry and irritate the oral mucosa.

🔸 Moistening the mouth is beneficial, but airway protection takes priority.

🔹 The priority is the client who is incontinent with watery stools because prolonged contact of stool with the skin rapidly increases the risk of skin breakdown, moisture-associated skin damage, and infection.

🔹 Frequent cleansing after episodes of fecal incontinence is essential to maintain skin integrity and patient comfort.

🔹 Watery stools contain digestive enzymes that can quickly damage the skin, especially over the sacral and perineal areas.

🔹 Prompt hygiene also reduces the risk of contamination, odor, and the spread of microorganisms.

🔹 Using priority frameworks, this client has the most immediate need requiring nursing intervention.

🔹 After cleansing, the nurse should apply a moisture barrier cream if indicated to protect the skin.

🔹 The remaining clients also require bathing, but their needs are less urgent than preventing skin damage from ongoing fecal incontinence.

🔹 Therefore, this client should be assisted with a bath first.

❌ An immobilized client who needs assistance with hygiene.

🔸 This client requires assistance with bathing but does not have the same immediate risk for skin damage as a client with fecal incontinence.

🔸 The nurse should assist this client after addressing the highest-priority need.

❌ A client with a stage 1 pressure injury.

🔸 A stage 1 pressure injury requires careful skin care and pressure relief, but active fecal incontinence poses a more immediate threat to skin integrity.

🔸 The pressure injury should be managed promptly after the incontinent client has been cared for.

❌ A client without a bath 2 days past admission.

🔸 Although bathing is important for hygiene and comfort, this situation is not urgent.

🔸 This client can safely wait until higher-priority clients have been cared for.

✅ Blank 1: Pressure injury

🔹 The client is at highest risk for a pressure injury because they have impaired mobility, meaning they may not reposition independently.

🔹 When a client stays in one position for too long, pressure reduces blood flow to the skin and underlying tissue.

🔹 Reduced circulation can cause tissue ischemia, skin breakdown, and eventually an open wound.

🔹 The risk is even higher because the client became incontinent of urine, which adds moisture to the skin.

🔹 Moisture from urine weakens the skin and makes it easier for pressure and friction to cause breakdown.

🔹 The client is also newly confused on Day 2, so they may not call for help or recognize the need to reposition.

🔹 Pressure injuries commonly occur over bony areas such as the sacrum, heels, hips, and elbows.

🔹 Nursing care should include frequent repositioning, skin checks, moisture control, clean linens, and pressure-relieving devices.

✅ Blank 2: Impaired mobility

🔹 Impaired mobility is the best evidence because the client required a bedpan due to impaired mobility on Day 1.

🔹 Immobility is a major risk factor for pressure injury because the client may not shift weight or relieve pressure independently.

🔹 A client who cannot move well is more likely to remain in one position for prolonged periods.

🔹 This increases pressure over bony prominences and decreases tissue perfusion.

🔹 Impaired mobility also increases dependence on staff for toileting, hygiene, turning, and repositioning.

🔹 The Day 2 urinary incontinence further increases the skin breakdown risk, but the listed evidence that best supports the risk is impaired mobility.

🔹 Drainage on the dressing is not the best evidence because the dressing had only a small amount of pink drainage and was intact.

🔹 Bowel sounds are not related to skin breakdown risk.

❌ Urinary stasis

🔸 Urinary stasis means urine remains in the bladder and does not flow normally, increasing UTI risk.

🔸 This client is voiding and later incontinent, so the main risk is skin breakdown, not urinary retention.

❌ Joint contracture

🔸 Joint contractures can occur with long-term immobility, but the immediate highest risk here is pressure injury.

🔸 The presence of urinary incontinence and impaired mobility makes skin breakdown the priority concern.

❌ Drainage on dressing

🔸 The dressing had only a small amount of pink drainage and was intact, which can be expected after surgery.

🔸 It does not provide the strongest evidence for the client’s highest risk.

❌ Bowel sounds

🔸 Hypoactive bowel sounds may occur after surgery or decreased mobility.

🔸 They do not support the risk for pressure injury.

🔹 The client reports weakness and dizziness when standing, indicating a high risk for orthostatic hypotension and falls.

🔹 The priority nursing intervention is to assist the client with standing and ambulation to prevent loss of balance and injury.

🔹 Direct supervision allows the nurse to assess the client's tolerance to position changes and intervene immediately if dizziness or instability occurs.

🔹 The nurse should encourage the client to change positions slowly, such as moving from lying to sitting, then standing gradually.

🔹 Assisting with ambulation reduces the likelihood of falls while promoting safe mobility and maintaining the client's independence.

🔹 The nurse should also use gait belts or assistive devices when appropriate to provide additional support.

🔹 This intervention directly addresses the client's immediate safety need and follows the nursing priority of preventing injury.

🔹 Therefore, assisting the client with standing and ambulation is the highest-priority intervention.

❌ Keep the lighting bright in the room and provide non-skid socks.

🔸 Good lighting and non-skid socks help reduce fall risk but do not address the client's immediate problem of dizziness upon standing.

🔸 These are supportive safety measures but are not the priority intervention.

❌ Place the client's personal items on the bedside table within reach.

🔸 Keeping personal items within reach helps reduce unnecessary movement and promotes safety.

🔸 However, it does not directly prevent a fall when the client becomes dizzy while standing.

❌ Keep the bed in low position and all side rails up.

🔸 Keeping the bed low is appropriate, but raising all four side rails is considered a restraint and may increase the risk of injury if the client attempts to climb over them.

🔸 Standard fall precautions include keeping the bed low with two side rails up unless otherwise indicated.

✅ "Would you like for a family member to help you with hygiene?"

🔹 Some cultures prefer that family members assist with personal hygiene rather than healthcare providers.

🔹 Asking this question respects the client's cultural beliefs and personal preferences.

🔹 It allows the client to participate in decisions regarding their care.

🔹 Family involvement may increase the client's comfort and sense of dignity.

🔹 The nurse should never assume that all clients prefer professional assistance.

🔹 Respecting cultural values helps build trust between the client and the healthcare team.

🔹 This approach supports culturally competent, patient-centered care.

🔹 Therefore, this is an appropriate nursing response.

✅ "What are your preferences for the use of soap and deodorant?"

🔹 Hygiene practices vary among cultures, including preferences for specific soaps, deodorants, fragrances, or cleansing products.

🔹 Asking about these preferences demonstrates respect for the client's cultural and personal beliefs.

🔹 It allows the nurse to individualize hygiene care according to the client's values.

🔹 Some clients may avoid certain products for religious, cultural, or skin-sensitivity reasons.

🔹 Respecting these preferences promotes comfort and dignity.

🔹 Open-ended questions encourage communication and strengthen the therapeutic relationship.

🔹 Culturally sensitive care improves patient satisfaction and cooperation.

🔹 Therefore, this is an appropriate response.

✅ "Would you prefer a care provider of your same gender to help you?"

🔹 Many cultures and religions prefer that personal hygiene be provided by a caregiver of the same gender.

🔹 The client's lack of eye contact and hesitation may indicate discomfort with receiving intimate care from a male nurse.

🔹 Asking respectfully gives the client the opportunity to express this preference without embarrassment.

🔹 Honoring gender preferences whenever possible preserves the client's privacy and dignity.

🔹 This approach reflects respect for cultural diversity and patient autonomy.

🔹 It also helps establish trust and promotes a therapeutic nurse-client relationship.

🔹 Nurses should never assume a client's preferences but should ask respectfully.

🔹 Therefore, this is one of the most culturally appropriate responses.

❌ "I am not comfortable with helping a female client with hygiene care. I will find someone who can help."

🔸 This statement focuses on the nurse's personal comfort rather than the client's needs and preferences.

🔸 Care should be based on the client's wishes, not the nurse's assumptions or discomfort.

❌ "Why have you not bathed for 4 days?"

🔸 This question may sound judgmental and could make the client feel embarrassed or defensive.

🔸 A therapeutic approach is to explore the client's preferences and concerns respectfully rather than questioning their behavior.