1. When turning an immobile bedridden client without assistance, which

action by the nurse best ensures client safety?

A. Securely grasp the client's arm and leg.

B. Put bed rails up on the side of bed opposite from

the nurse.

C. Correctly position and use a turn sheet.

D. Lower the head of the client's bed slowly.

Rationale:

Because the nurse can only stand on one side of the bed, bed rails should be up on

the opposite side to ensure that the client does not fall out of bed. Option A can

cause client injury to the skin or joint. Options C and D are useful techniques

while turning a client but have less priority in terms of safety than use of the bed

rails.

2. The nurse identifies a potential for infection in a client with partialthickness (second-degree) and full-thickness (third-degree) burns. What

intervention has the highest priority in decreasing the client's risk of

infection?

A. Administration of plasma expanders

B. Use of careful handwashing technique

C. Application of a topical antibacterial cream

D. Limiting visitors to the client with burns

Rationale:

Careful handwashing technique is the single most effective intervention for the

prevention of contamination to all clients. Option A reverses the hypovolemia that

initially accompanies burn trauma but is not related to decreasing the proliferation

of infective organisms. Options C and D are recommended by various burn

centers as possible ways to reduce the chance of infection. Option B is a proven

technique to prevent infection.

3. The nurse is aware that malnutrition is a common problem among clients

served by a community health clinic for the homeless. Which laboratory

value is the most reliable indicator of chronic protein malnutrition?