A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?
Use warm water when bathing the client.
Place a donut-shaped cushion in the client's chair.
Massage reddened areas over bony prominences.
Maintain the client in high-Fowler's position.
The Correct Answer is A
The correct answer is choice A. Use warm water when bathing the client.
Choice A rationale:
Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.
Choice B rationale:
Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.
Choice C rationale:
Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.
Choice D rationale:
Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is D
Explanation
The correct answer is choice **d. Providing client information to another nurse at change of shift**.
Choice A rationale:
Sharing the client's prognosis with a family member without the client's consent violates the client's right to confidentiality. The nurse should only disclose information to family members if the client has provided permission or if it is necessary for the client's care.
Choice B rationale:
Discussing the client's status with a member of the spiritual support team may be appropriate if the client has consented to spiritual support and the nurse limits the discussion to information relevant to the spiritual care. However, disclosing the client's diagnosis or other sensitive information without the client's consent would still be a breach of confidentiality.
Choice C rationale:
Collaborating with a nurse from another unit about the client's care is appropriate if it is necessary for the client's treatment and if the discussion is limited to information relevant to the client's care. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Choice D rationale:
Providing client information to another nurse at change of shift is necessary for the continuity of the client's care and is considered an appropriate disclosure within the healthcare team. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
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