A hospital is initiating protocol on hospital acquired pressure injury prevention. Which intervention should the nurse question as incorrect?
Turn and reposition every 2 hours.
Completing personal hygiene and apply skin barrier products.
Reposition the patient every 8 hours.
Cushion vulnerable parts of the body and redistribute body weight.
The Correct Answer is C
A. Turn and reposition every 2 hours: Repositioning every 2 hours is a standard evidence-based intervention to prevent pressure injuries. Frequent repositioning relieves sustained pressure over bony prominences, improves tissue perfusion, and reduces the risk of skin breakdown.
B. Completing personal hygiene and apply skin barrier products: Maintaining skin hygiene and using moisture barrier creams protects skin from irritants such as urine, feces, and sweat. These measures help preserve skin integrity, reduce maceration, and prevent breakdown, making them appropriate preventive interventions.
C. Reposition the patient every 8 hours: Repositioning only every 8 hours is inadequate for pressure injury prevention. Prolonged pressure beyond 2–3 hours can compromise capillary blood flow, leading to tissue ischemia and increased risk of skin breakdown. This intervention does not align with current best practices and should be questioned.
D. Cushion vulnerable parts of the body and redistribute body weight: Using pillows, foam pads, or specialized mattresses to offload pressure on bony prominences is a recommended intervention. Redistributing weight reduces localized pressure, improves circulation, and minimizes the risk of developing pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Calculation:
- Identify the given time in 24-hour format
Given time: 2100
- Convert to 12-hour format
Since 2100 is greater than 1200, subtract 1200 to convert to PM time: 2100 − 1200 = 900
- Add the colon and AM/PM notation
= 9:00 pm
Correct Answer is ["90.9"]
Explanation
Calculation:
- Identify the total volume and infusion time
Total Volume: 1000 mL
Time: 11 hours
- Calculate the flow rate
Flow Rate (mL/hr) = Total Volume ÷ Time
Flow Rate = 1000 ÷ 11
Flow Rate ≈ 90.909
- Round to the nearest tenth
= 90.9 mL/hr
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