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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.: Answer: 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. 2. The nurse identifies a potential for infection in a client with partial-thickness (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: Answer: 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. 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? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level: Answer: A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long halflife, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition. [Show More]

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