A client is bedridden and appears to be frail and malnourished. Which nursing interventions will most effectively prevent skin injury? (Select all that apply.)

Cleansing the skin routinely after soiling occurs.

Applying moisturizer to dry areas of skin.

Using a Hoyer lift for all transfers.

Massaging the client’s reddened shoulders and heels.

Repositioning the client once per shift.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.

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Correct Answer is C

Explanation

Choice A reason: This is not the correct answer because opioids are a class of medications that act on the opioid receptors in the brain and spinal cord to reduce pain perception and emotional response. Opioids do not have a direct effect on tissue inflammation or bone healing, but they can cause side effects such as constipation, nausea, sedation, respiratory depression, and addiction.

Choice B reason: This is not the correct answer because anticoagulants are a class of medications that prevent or reduce the formation of blood clots by interfering with the clotting factors or platelets. Anticoagulants do not have a direct effect on tissue inflammation or bone healing, but they can increase the risk of bleeding and hematoma formation, which can impair the blood supply and oxygen delivery to the injured tissues.

Choice C reason: This is the correct answer because NSAIDs are a class of medications that inhibit the enzyme cyclooxygenase (COX), which is involved in the synthesis of prostaglandins, which are inflammatory mediators that cause pain, swelling, and fever. NSAIDs can decrease tissue inflammation and pain, but they can also delay bone healing by reducing the formation of osteoblasts, which are cells that build new bone tissue.

Choice D reason: This is not the correct answer because narcotics are another term for opioids, which are a class of medications that act on the opioid receptors in the brain and spinal cord to reduce pain perception and emotional response. Narcotics do not have a direct effect on tissue inflammation or bone healing, but they can cause side effects such as constipation, nausea, sedation, respiratory depression, and addiction.

A. Fistula B. Hemorrhage C. Infection D. Evisceration

Correct Answer is A

Explanation

Choice A reason: Fistula is a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin. Fistula can occur as a result of infection, inflammation, trauma, surgery, or congenital defect. Fistula can cause pain, bleeding, discharge, or leakage of fluids or gases from the affected organs or tissues. Fistula can also increase the risk of infection, obstruction, or perforation of the involved organs or tissues.

Choice B reason: Hemorrhage is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an excessive or uncontrolled bleeding from the wound site. Hemorrhage can occur as a result of trauma, surgery, infection, or coagulation disorder. Hemorrhage can cause pain, swelling, bruising, or shock at the wound site. Hemorrhage can also lead to blood loss, anemia, or hypovolemia.

Choice C reason: Infection is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an invasion and multiplication of microorganisms in the wound site. Infection can occur as a result of contamination, poor hygiene, or impaired immunity. Infection can cause pain, redness, warmth, swelling, or pus at the wound site. Infection can also trigger inflammation, fever, or systemic illness.

Choice D reason: Evisceration is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is a protrusion of internal organs or tissues through the wound site. Evisceration can occur as a result of dehiscence, which is a separation or splitting open of the wound edges. Evisceration can cause pain, bleeding, or shock at the wound site. Evisceration can also expose the internal organs or tissues to injury, infection, or necrosis.

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A client is bedridden and appears to be frail and malnourished. Which nursing interventions will most effectively prevent skin injury? (Select all that apply.)

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