A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

instruct the client to dig their heels into the bed to push themselves upwards.

Assist the client with a trapeze to raise their body while staff assists with repositioning

Have two to three staff members pull the client up in bed when needed.

Elevate the head of the bed 90° for bedridden clients.

Answer and Explanation

The Correct Answer is B

A. Instruct the client to dig their heels into the bed to push themselves upwards: This increases friction on the heels, which can lead to skin breakdown.

B. Assist the client with a trapeze to raise their body while staff assists with repositioning. Using a trapeze allows the client to lift themselves slightly off the bed, reducing the friction and shear forces that can cause skin injuries during repositioning.

C. Have two to three staff members pull the client up in bed when needed: This increases the risk of friction injuries, especially if the client is not lifted properly.

D. Elevate the head of the bed 90° for bedridden clients: High elevation of the bed can increase the risk of shear injuries due to sliding down in bed.

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Correct Answer is D

Explanation

A. "You have had a gastrointestinal bleed.": While a GI bleed can cause anemia and fatigue, it is not a direct cause of fatigue in sickle cell anemia.

B. "You have a low ferritin level.": Low ferritin indicates iron deficiency anemia, not directly related to sickle cell anemia.

C. "You have an autoimmune disease.": Sickle cell anemia is a genetic disorder, not an autoimmune disease.

D. "You have fewer red blood cells." Sickle cell anemia results in a decreased number of healthy red blood cells (RBCs) because the sickled cells are fragile and prone to breaking apart. This leads to anemia, which reduces the blood's ability to carry oxygen, causing fatigue and tiredness.

A. impaired skin integrity B. Alteration in activity tolerance C. Impaired tissue perfusion D. Alteration in body image

Correct Answer is C

Explanation

A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.

B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.

C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.

D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.

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A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sickle cell anemia. The client asks. "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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