Thevnnursevnseesvninvnthevnpatient'svnrecordvnthatvnthevnpatientvnhasvnavnBradenvn
scorevnofvn20.vnWhichvnnursingvnactionvnisvnthevnnursevnmostvnlikelyvntovnperfor
mvninvnthevncarevnofvnthisvnpatient?vn-vncorrectvnanswer✔ ✔
Continuevnroutinevnassessments
Avnthin,vnmalnourishedvnpatientvnrequiresvnemergencyvnabdominalvnsurgery.v
nAftervnthevnsurgery,vninvnordervntovnpromotevnwoundvnhealing,vnwhatvndoesvnth
evnnursevnencourage?vn-vncorrectvnanswer✔ ✔ High-qualityvnproteinvndiet
Thevnnursevnisvndirectingvnthevnhomevnhealthvnunlicensedvnassistivevnpersonne
lvn(UAP)vninvnthevncarevnofvnanvnoldervnadultvnpatient.vnThevnpatientvnreportsvndr
yvnskinvnandvnwantsvnhelpvninvnapplyingvnanvnemollientvncream.vnWhatvndoesvnt
hevnnursevndirectvnthevnUAPvntovndo?vn-vncorrectvnanswer✔ ✔
Assistvnthevnpatientvntovnsoakvnforvn10vnminutesvninvnavnwarmvnbathvnandvnthen
vnapplyvnthevncreamvntovnslightlyvndampvnskinvnwithinvn2vntovn3vnminutesvnaftervn
bathing
Whichvnpatientsvnarevnatvnriskvnforvnpressurevnulcers?vn-vncorrectvnanswer✔
✔ -Avnmiddle-agedvnquadriplegicvnpatientvnwhovnisvnalertvnandvnconversant
-AvnbedriddenvnpatientvnwhovnisvninvnthevnlatevnstagevnofvnAlzheimer'svn
-
Avnveryvnoverweightvnpatientvnwhovnmustvnbevnassistedvntovnmovevninvnthevnbed
, -Avnthinvnpatientvnwhovnsitsvnforvnlongervnperiodvnandvnrefusesvnmeals
Thevnnursevnisvncaringvnforvnanvnobesevnpatientvnwhovnhasvnbeenvnonvnbedrestvnf
orvnseveralvndays.vnThevnnursevnobservesvnthatvnthevnpatientvnisvnbeginningvntovn
developvnrednessvnonvnthevnsacralvnarea.vnWhatvninterventionvnisvnusedvntovndec
reasevnthevnshearingvnforce?vn-vncorrectvnanswer✔ ✔
Placevnthevnpatientvninvnavnside-lyingvnposition
Thevnnursevnisvnreviewingvnthevnresultsvnofvnavnpressurevnmappingvnonvnpatientv
natvnhighvnriskvnforvnpressurevnulcers.vnThevnmapvnshowsvnavnredvnareavnovervnthe
vnhips.vnHowvndoesvnthevnnursevninterpretvnthisvnevidence? vn-vncorrectvnanswer
✔ ✔ Greatervnheatvnproductionvnassociatedvnwithvngreatervnpressure
Thevnnursevnisvnassessingvnthevnnutritionalvnstatusvnofvnavnpatientvnatvnriskvnforvns
kinvnbreakdownvnwhovnhasvnbeenvnrefusingvntovneatvnthevnhospitalvnfood.vnWhi
chvnindicatorvnisvnthevnmostvnsensitivevninvnidentifyingvninadequatevnnutritionvn
forvnthisvnpatient?vn-vncorrectvnanswer✔ ✔
Prealbuminvnlevelvnofvn17.5vnmg/dL
Seeingvnavnreddenedvnareavnonvnavnpatient'svnskin,vnthevnnursevnpressesvnfirmlyvn
withvnfingersvnatvnthevncentervnofvnthevnarevnandvnseevnthatvnthevnareavnblanchesvn
withvnpressure.vnThevnnursevninterpretsvnthisvnfindingvnasvnchangesvnrelatedvnto
vnwhichvnfactor? vn-vncorrectvnanswer✔ ✔ Bloodvnvesselvndilation