A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?
Check the client's skin every 4 hr.
Place a donut-shaped cushion under the client.
Turn the client every/hr.
Place the client in a 30° lateral position.
The Correct Answer is D
A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.
B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.
C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.
D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Your baby needs to suck on a pacifier" is not necessarily the best advice for this situation. While pacifiers can help some babies self-soothe, crying is often a sign of an unmet need, and further assessment is needed to determine the cause of the crying. Offering a pacifier without addressing other potential causes might overlook the root issue.
B. "Swaddling your baby snugly in a blanket might help soothe her" is correct. Swaddling can help calm a newborn by providing a sense of security and warmth, mimicking the conditions of the womb. It is a common technique used to soothe babies.
C. "Breastfed babies are usually fussy from swallowing too much air during feedings" is incorrect. While some babies may have mild gas or discomfort from swallowing air, excessive crying is not typically due to this alone, especially if the baby has been fed properly and burped.
D. "Breastfed babies often need to be supplemented with formula" is not appropriate. While some breastfeeding difficulties can occur, advising formula supplementation without further investigation could undermine the breastfeeding process and should only be suggested after careful assessment and if truly necessary.
Correct Answer is B
Explanation
A. "Provide homeschooling for your child" is not a necessary instruction. Children with cystic fibrosis can attend school, and with appropriate care, they can often manage their condition and participate in normal activities.
B. "Have your child wear a medical identification wristband" is correct. A medical identification wristband is important for children with cystic fibrosis as it can provide crucial information in an emergency, such as their diagnosis and specific care needs.
C. "Ensure that your child does not receive the influenza vaccine annually" is incorrect. Children with cystic fibrosis are at higher risk for respiratory complications and should receive the influenza vaccine annually to help prevent infection and reduce the risk of exacerbations.
D. "Do not include your child when making decisions about treatment" is incorrect. Involving children in their treatment decisions, as appropriate for their age and understanding, is important for fostering autonomy and ensuring they feel empowered in managing their condition.
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