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Difficulty: MediumBasic Care and Comfort

A nurse is developing a plan of care for a 75-year-old client who is on strict bed rest due to severe weakness from bacterial pneumonia. The client has also begun experiencing sudden periods of confusion in the evenings. Which of the following interventions should the nurse include in the plan of care? Select all that apply.

  1. Float the client's heels off the mattress by placing a pillow lengthwise under the lower legs.Answer
  2. B
    Delegate the admission skin integrity and pressure injury risk assessment to the unlicensed assistive personnel (UAP).
  3. C
    Place a rolled blanket directly behind the client's knees to maintain sharp knee flexion and prevent sliding.
  4. Provide a gentle back rub and dim the overhead lighting to promote relaxation before sleep.Answer
  5. E
    Explain to the family that the sudden evening confusion is a normal age-related cognitive change.
  6. Perform frequent oral hygiene using a soft-bristled brush or moistened sponge swab.Answer

Answer

The correct interventions are floating the heels off the mattress, providing a back rub with dimmed lighting, and performing frequent oral hygiene.
The correct interventions directly address the client's fundamental needs for skin protection, sleep promotion, and hygiene. Floating the heels prevents pressure ulcers, providing a back rub and dimming lights facilitates restorative sleep, and frequent oral care maintains mucous membrane health.

Step-by-Step Solution

1
Evaluate the client's risk for skin breakdown due to bed rest and weakness.
Identify the need to protect bony prominences by floating the heels with a pillow.
Immobility greatly increases the risk of pressure injuries, and basic care must prioritize skin integrity.
2
Assess the need for non-pharmacological comfort and sleep promotion.
Select interventions like back rubs and environmental noise/light reduction.
Illness and hospital environments often disrupt normal sleep patterns, requiring proactive nursing comfort measures.
3
Identify hygiene requirements for a client on strict bed rest.
Include frequent oral care in the plan.
Regular oral hygiene maintains mucosal integrity, prevents further infection, and enhances client comfort.
4
Analyze the remaining distractors for contraindicated nursing practices.
Exclude delegating assessments to UAP, using improper knee positioning, and dismissing acute confusion as normal aging.
These actions compromise client safety, violate delegation principles, and ignore signs of acute physiological distress.

Key Concept

Basic care and comfort encompasses interventions that maintain skin integrity, promote sleep, ensure proper hygiene, and protect the client from physiological harm while avoiding unsafe positioning or improper delegation.
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Topics

Basic Care and Comfort

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