A nurse is caring for a child in the PICU. To prevent pressure ulcers, which intervention should the nurse include in the child's plan of care?
Avoid the use of a draw sheet when turning
Post a turning schedule at the client's bedside
Vigorously massage lotion into bony prominences
Turn and reposition the client at least every 4 hours
The Correct Answer is B
Turning and repositioning the client at regular intervals is essential for preventing pressure ulcers in pediatric clients, especially those in the PICU who may be immobilized or have limited mobility due to their condition or treatment. Repositioning helps relieve pressure on bony prominences and redistributes pressure on the skin, reducing the risk of pressure ulcers. Turning schedules should be individualized based on the child's condition, mobility, and risk factors for pressure ulcers.
A. Avoid the use of a draw sheet when turning: Using a draw sheet can facilitate safe and smooth turning of the client without causing shear or friction forces. It helps distribute the weight evenly and reduces the risk of injury to the client or caregiver during the turning process. Therefore, avoiding the use of a draw sheet may increase the risk of pressure ulcers rather than prevent them.
B. Post a turning schedule at the client's bedside: While posting a turning schedule may serve as a reminder for staff, it alone does not provide direct intervention to prevent pressure ulcers. The crucial aspect is implementing the turning schedule consistently and ensuring that the client is repositioned at appropriate intervals.
C. Vigorously massage lotion into bony prominences: Massaging lotion into bony prominences can increase friction and shear forces on the skin, potentially causing tissue damage rather than preventing pressure ulcers. Additionally, vigorous massage may be uncomfortable or painful for the client, especially if they have fragile skin or existing pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The calorie needs of toddlers vary depending on factors such as age, weight, height, activity level, and metabolism. 3,000 calories per day is likely to be excessive for most toddlers.
B. Although calorie intake is important for growth and development, the emphasis should be on the nutritional quality of the foods rather than solely on the quantity of calories consumed. Providing nutrient-rich foods ensures that the toddler receives essential vitamins, minerals, and other nutrients necessary for growth and development.
C. Vitamin supplementation may be necessary for some toddlers but it should be done under the guidance of a healthcare provider to ensure appropriate dosing and to avoid potential overdose or adverse effects.
D. An increased appetite alone does not guarantee adequate nutrition if the quality of the foods consumed is poor.
Correct Answer is D
Explanation
A. 15 angle is for intradermal injection not for intramuscular
B. The needle should be inserted into the middle third of the deltoid muscle, which is typically 2 to 3 finger widths below the acromion process.
C. A smaller gauge needle, such as 22 or 23, is often used for pediatric vaccinations to minimize discomfort. This should, however, be adjusted accordingly based on individual characteristics
D. Ashorter needle length, such as 1.8 mm (0.5 in), is typically appropriate for pediatric deltoid injections to avoid deep penetration
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