Practice Question
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)
Answer Choices:
Correct Answer:
Minimize skin exposure to moisture
Rationale:
🔷 Moisture-associated skin damage (incontinence/sweat) macerates skin → pressure injury risk.
🔷 Heel off-loading (“float the heels”) removes pressure over calcanei—common ulcer sites.
🔷 Repositioning q2h is the standard; q4h is too infrequent for prevention.
🔷 Avoid massaging erythema—microvascular damage can worsen tissue injury.
🔷 Powders can cake/irritate and do not replace moisture-barrier products.
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This question is from Custom NUR213 Final Assessment FA 1 2025 Aessment 1 which contains 60 questions.
More Questions from This Exam
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?
Answer Choices:
A. "l will take one aspirin every day."
B. “I will closely follow a high-purine diet.”
C. “I will limit my alcohol intake.”
D. "l will limit my fluid intake to 1 liter per day."
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Answer Choices:
A. History of neurologic deficits lasting less than 1 hr
B. Maintains consciousness
C. Gradual onset of several hours
D. Manifestations preceded by a severe headache
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
Answer Choices:
A. Obtain a central venous pressure.
B. Palpate pulse pressure.
C. Auscultate cuff blood pressure.
D. Monitor the pulmonary artery pressure.
A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of a postoperative infection? (Select All that Apply.)
Answer Choices:
A. Absence of ketones in urine
B. Increased hemoglobin
C. Negative leukocyte esterase in urine
D. Increased band neutrophils
E. Elevated erythrocyte sedimentation rate
From Exam
Custom NUR213 Final Assessment FA 1 2025 Aessment 1
60 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 5
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