A nurse is caring for a bedridden client who shows early signs of skin breakdown on the sacrum. Which intervention should the nurse prioritize to address this issue?
Massage the reddened area to improve circulation.
Apply a moisture barrier cream to the sacral area.
Reposition the client every 4 hours.
Elevate the head of the bed to 45°.
The Correct Answer is B
A. Massage the reddened area to improve circulation: Massaging a reddened area (likely a Stage 1 pressure injury) can cause further damage to the underlying blood vessels and increase the risk of deeper tissue injury.
B. Apply a moisture barrier cream to the sacral area: This is a crucial intervention, especially if the client is incontinent, as it protects the skin from chemical irritation and maceration. However, it does not address the primary cause: unrelieved pressure.
C. Reposition the client every 4 hours: For a bedridden client with signs of breakdown, the standard of care requires repositioning at least every 2 hours (and often more frequently) to significantly reduce the risk of tissue ischemia caused by prolonged pressure. Repositioning every 4 hours is inadequate.
D. Elevate the head of the bed to 45°: The head of the bed should be kept at or below 30° (unless medically contraindicated) to minimize the effects of shear and friction on the skin of the sacrum and coccyx. Elevating to 45° increases shear and pressure risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The wound is contaminated with dirt or debris: While dirt can cause discoloration, the thick, foul-smelling, green nature of the drainage strongly suggests an active, specific bacterial infection, not just simple contamination.
B. The wound is healing normally: Normal healing involves serous (clear/watery) or serosanguineous (pink/watery) drainage. Thick, colored, purulent drainage with a foul odor is a cardinal sign of infection.
C. The wound is showing signs of older bleeding: Older bleeding would result in sanguineous (dark red/brown) or serosanguineous drainage. Green, thick fluid is pus, indicative of infection.
D. The wound is infected with Pseudomonas aeruginosa:The classic clinical presentation of wound drainage that is green or blue-green, often with a distinctly sweet, musty, or foul odor, is highly characteristic of an infection caused by the bacterium Pseudomonas aeruginosa. Immediate wound culture and treatment based on facility protocol are required.
Correct Answer is B
Explanation
A. Check the patient's blood sugar levels: This is an important step in assessing a diabetic patient whose high blood sugar can impair healing, but it is not the most immediate priority for an actively infected wound.
B. Assess for signs of systemic infection: A foul odor (purulent drainage) indicates a localized infection. The priority is to assess if that infection is spreading systemically (sepsis) by checking for signs like fever, tachycardia, hypotension, and altered mental status. This assessment dictates the urgency of treatment (e.g., blood cultures, IV antibiotics).
C. Measure the wound dimensions: This is a routine, necessary step for wound documentation but is secondary to assessing the patient's immediate physiological status and the risk of life-threatening sepsis.
D. Apply a new dressing over the wound: This is an expected intervention but is secondary to a thorough assessment for systemic involvement, which guides immediate medical interventions.
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