A bedbound client is at risk for pressure ulcers. Which nursing action is most effective in preventing the development of ulcers?

Apply heat to bony prominences

Reposition the client every 2 hours

Massage reddened areas

Increase fluid restriction

Answer and Explanation

The Correct Answer is B

A. Apply heat to bony prominences: Applying heat to pressure points can increase local tissue metabolic demand and may worsen ischemia; heat is not a preventive measure for pressure ulcers.

B. Reposition the client every 2 hours: Regular repositioning relieves prolonged pressure over bony prominences, redistributes weight, and is a primary preventive intervention to reduce pressure ulcer risk.

C. Massage reddened areas: Massaging areas of redness can further damage capillaries and underlying tissue and is generally discouraged; instead, avoid pressure and inspect frequently.

D. Increase fluid restriction: Adequate hydration supports skin integrity; restricting fluids can impair tissue perfusion and healing and would not prevent ulcers.

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Correct Answer is C

Explanation

A. "I will review your chart and be right back.": This avoids the patient's expressed anxiety and delays addressing concerns; it doesn’t provide reassurance or information.

B. "This is nothing to worry about. I won't hurt you.": Minimizes the patient's feelings and can erode trust; reassurance should be realistic and informative.

C. "I will tell you everything that I am doing.": Explaining each step reduces uncertainty and empowers the patient, which is the most therapeutic choice for anxious clients.

D. "I have to do this, so just relax. It won't take long.": Dismissive and directive; does not acknowledge the patient's anxiety or provide needed information.

A. Stage I B. Stage ii C. Stage iii D. Stage iv

Correct Answer is A

Explanation

A. Stage I pressure injury is characterized by intact skin with a localized area of nonblanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. The patient in the prompt has intact skin on their heel with a nonblanchable reddish area, which fits this description perfectly.

B. STAGE II: A Stage II pressure injury involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red or pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Since the patient's skin is intact, Stage II is incorrect.

C. STAGE III: A Stage III pressure injury involves full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough and/or eschar may be present. This is a much more severe injury than what is described.

D. STAGE IV: A Stage IV pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This is the most severe stage and is clearly not what is pictured or described.

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A bedbound client is at risk for pressure ulcers. Which nursing action is most effective in preventing the development of ulcers?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be the most appropriate?

Correct Answer is C

Explanation

While performing a skin assessment on a bedridden patient, you note a reddish area on the patient's left heel. The skin is intact. The area is nonblanchable. See the picture below. Based on your findings, you suspect this may be which of the following pressure injury?

Correct Answer is A

Explanation

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