A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
Reposition the client every 2 hr.
Elevate the head of the client's bed 45°
Massage the client's bony prominences.
Provide the client with a high-calorie diet.
The Correct Answer is A
A. Reposition the client every 2 hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.
B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.
Correct Answer is D
Explanation
Correct answer: D
A.While it is important to ensure the can of formula is clean, it should be wiped with soap and water or a disinfectant wipe, not an alcohol wipe.
B.Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.
C.The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.
D.It is standard practice to flush the NG tube with 30 mL of sterile water (or as per facility guidelines) before administering an enteral feeding. This helps ensure the tube is patent, reduces the risk of clogging, and ensures the feeding formula flows smoothly. Flushing before the feeding also helps clear the tube of any residual formula, preventing cross-contamination.
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