A nurse caring for an 88-year-old client on a medical/surgical floor knows that there are many factors that can affect skin breakdown and lead to pressure ulcer formation. Select which answers can help to prevent pressure ulcers. Select all that apply. One, some, or all options may be correct.
Decreasing protein in a client's diet.
Placing the client on a turning schedule every 2 hours.
Keeping a client in bed as long as they want to be.
Performing active ROM exercises even when a client is on bed rest.
Massaging reddened areas of the skin to improve circulation.
Correct Answer : B,D
A. Decreasing protein in a client’s diet: Protein is needed for skin repair and immune function; low protein increases risk of pressure ulcers.
B. Placing the client on a turning schedule every 2 hours: Repositioning is essential to relieve pressure and prevent tissue ischemia.
C. Keeping a client in bed as long as they want to be: Immobility contributes to pressure ulcer risk. Clients should be encouraged to mobilize when safe.
D. Performing active ROM exercises even when a client is on bed rest: Movement promotes circulation and helps prevent stiffness, contractures, and skin breakdown.
E. Massaging reddened areas of the skin to improve circulation: Massaging over erythematous areas can damage fragile capillaries and worsen skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client is working daily with PT and OT: Regular participation in physical and occupational therapy indicates mobility and activity, which lowers the likelihood of pressure injury development.
B. The client is eating 75–100% of their daily meals: Adequate oral intake supports nutrition and tissue integrity, reducing pressure ulcer risk.
C. The client is immobile and is currently bedbound: Prolonged immobility and being bedbound increase pressure over bony prominences and are strong risk factors for pressure injury formation.
D. The client appears to have a capillary refill of less than 2 seconds: Capillary refill under 2 seconds suggests adequate peripheral perfusion, which does not by itself indicate increased risk for pressure injuries.
Correct Answer is A
Explanation
A. The client will sit in the chair for each meal by end of day two of admission: This statement is client-centered, specific (sit in chair for meals), measurable (each meal), achievable/relevant to mobility, and time-bound (by end of day two), matching SMART criteria.
B. The client will transfer to the chair with assist of one person: This describes an outcome but lacks a time frame and measurable deadline, so it does not fully meet SMART criteria as written.
C. The nurse will reposition the client every hour while the client is awake: This sentence describes a nursing action/intervention rather than a client-focused outcome goal; SMART goals should state the client outcome, not only the nurse’s tasks.
D. The nurse will assist the client to ambulate in the hall by the second day: This is phrased as a nursing action rather than a client outcome; converting it to a client-centered SMART goal (e.g., “The client will ambulate 20 feet in the hall with one-person assist by day two”) would make it meet SMART criteria.
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