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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B, A, C, D

Explanation

B. Inject 20 units of air into the NPH insulin vial. Injecting air into the NPH vial first helps equalize the pressure. A. Inject 10 units of air into the regular insulin vial. This prepares the regular insulin vial for withdrawal without creating a vacuum. C. Withdraw 10 units of regular insulin. After injecting air into the regular insulin vial, withdraw the regular insulin first to avoid contaminating it with the NPH insulin. D. Withdraw 20 units of NPH insulin. Finally, withdraw the NPH insulin after the regular insulin.

A. Identify the clients at greatest risk for development of pressure ulcers. B. Turn and position each client every 2 hr. C. Use a barrier cream when performing perineal care. D. Supervise clients to ensure adequate nutritional intake.

Correct Answer is A

Explanation

A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B, A, C, D

Explanation

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?

A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

The health care provider has written the following orders for a client with bounding peripheral pulses, weight gain of 2 lb., pitting edema, and moist crackles bilaterally. Which order will the nurse complete first?

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?