Question

question: 60 of 60
a nurse is assisting in the care of a client.
exhibit 1 exhibit 2
nurses notes
4 days ago:
client admitted to skilled nursing facility. client has decreased mobility and is confined to their bed, client only able to communicate with moans. client is incontinent of urine and stool. client receiving tube feeding for nutrition. braden score 7.
drag words from the choices below to fill in each blank in the following sentence.
when prioritizing care for the client, the nurse should first target 1, target 2, and target 3.
options for targets
evaluate the client’s response to the plan of care.
plan a turning and positioning schedule.
apply hydrocolloid dressing to the client’s sacrum.
request a prescription for pressure redistribution bed
perform passive range of motion exercises
target 1
target 2
target 3

Explanation:

The client has a Braden score of 7 (indicating high risk for pressure ulcers), is bed - confined, incontinent, and on tube feeding. When prioritizing care, the first step is to request a pressure redistribution bed (to address the pressure ulcer risk at its root by changing the bed setup). Then, plan a turning and positioning schedule (to further reduce pressure on skin by regularly moving the client). Finally, perform passive range of motion exercises (to maintain joint mobility as the client has decreased mobility).

Answer:

Target 1: Request a prescription for pressure redistribution bed
Target 2: Plan a turning and positioning schedule
Target 3: Perform passive range of motion exercises