NUR 320 Foundations of Nursing Exam #4 Summer 2025

The priority client is the newly admitted client refusing to be turned, as this behavior increases the immediate risk for pressure injury, impaired skin integrity, and complications from immobility. Early intervention and patient education are crucial to prevent rapid skin breakdown, ensure safety, and establish trust and compliance with the care plan. Newly admitted clients also require close assessment for baseline condition and orientation to care expectations.

Immobility is one of the primary risk factors for pressure injury formation. When a client is bedbound, constant pressure on bony prominences reduces blood flow to tissues, leading to ischemia and skin breakdown. Without frequent repositioning, adequate nutrition, and pressure relief, tissue damage can progress to ulcer formation. Thus, a bedbound client is at the highest risk for developing pressure injuries.

Forcing or “making” a dying client eat is inappropriate and potentially harmful. As the body naturally begins to shut down, appetite and the ability to swallow decrease. Forcing food can cause choking, aspiration, or discomfort. End-of-life care focuses on comfort measures, respecting the client’s wishes, and relieving symptoms rather than promoting nutrition. The nurse should educate the AP that loss of appetite is a normal part of the dying process.

The liver is the primary organ responsible for drug metabolism. It contains enzymes, particularly from the cytochrome P450 system, which chemically alter medications into inactive or more easily excretable forms. This process, known as biotransformation, helps prevent drug toxicity and maintains therapeutic levels. Impaired liver function (e.g., due to cirrhosis or hepatitis) can delay metabolism, leading to drug accumulation and adverse effects—making liver assessment vital in medication management.

High-risk medications are drugs that carry a higher risk of causing significant patient harm when used incorrectly. According to the Institute for Safe Medication Practices (ISMP), medications such as potassium, insulins, opioids, chemotherapeutic agents, and heparin require special handling, double-checks, and monitoring. Errors with these medications can result in severe hypoglycemia, bleeding, respiratory depression, or cardiac arrhythmias, making them critical to administer with precision and vigilance.

The Braden Scale is a validated assessment tool used to determine a client’s risk for developing pressure injuries (skin breakdown). It evaluates six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category is scored from 1 to 4, with lower total scores indicating higher risk. Early identification using the Braden Scale enables the nurse to implement preventive measures such as repositioning, skin protection, and moisture control.

A SMART goal is Specific, Measurable, Achievable, Relevant, and Time-bound. Option A clearly identifies who (the client), what (sit in the chair for each meal), and when (by end of day two). This outcome is client-centered, measurable, realistic, and time-specific, reflecting progress toward improved mobility and independence. It aligns with nursing care goals to increase activity safely and gradually.

This statement is therapeutic and supportive, acknowledging the client’s fear and providing emotional reassurance without giving false promises. By expressing understanding and a commitment to stay, the nurse conveys empathy, calm presence, and trust — essential for reducing anxiety in a panicking, critically ill client. This promotes psychological safety and emotional stability in a life-threatening situation.

B. Placing the client on a turning schedule every 2 hours
Repositioning every two hours helps redistribute pressure over bony prominences, promoting blood flow and preventing tissue ischemia—the leading cause of pressure injuries. This is one of the most essential nursing interventions for immobile clients.
D. Performing active ROM exercises even when a client is on bed rest
Active or passive range of motion exercises stimulate circulation, maintain joint flexibility, and reduce muscle atrophy. Improved blood flow nourishes skin tissues, lowering the risk of pressure ulcer development in bedbound patients.