A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.1.78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory 2.70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound 3.62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 4.25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

1. A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.
1.
78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory

2.
70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound

3.
62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift

4.
25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

B!

Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.
A, B, D, & E!

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.
1. 70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound

2. 62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift

3. 25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

4. 78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory

Risk factors for pressure ulcers include inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed, making the 70-year-old male at greatest risk. An inability to sense or move the left side will inhibit changing positions without assistance, making the 62-year-old female post CVA next at risk. Urine and fecal incontinence may result in skin breakdown in the perineal and sacral areas. The 25-year-old male client is at some risk by not being able to communicate verbally and having urinary incontinence. The client's nutritional status is acceptable and client is able to move. The 78-year-old female client has minimal risk factors. Because she is scheduled for a knee replacement, which is an elective procedure, it can be assumed that her general health is within acceptable limits. Also, she is continent and ambulatory.

1

The correct dose is 1 mL. Use ratio and proportion to solve the problem.