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.
B
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. - CORRECT ANSWER
The nurse identifies a potential for infectionin a client with partial-thickness (second-degree) and fullthickness (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
B
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. - CORRECT ANSWER
Thenurse 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?
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