A nurse is caring for a client who is at risk for a pressure injury.
Which of the following actions should the nurse take?
Massage the client's bony prominences.
Reposition the client every 4 hr.
Elevate the head of the client's bed 45°.
Provide the client with a high-calorie diet.
The Correct Answer is D
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.
Choice B rationale:
It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.
Choice C rationale:
Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.
Choice D rationale:
Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.
Correct Answer is B
Explanation
Choice A rationale:
Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.
Choice B rationale:
Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.
Choice C rationale:
Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.
Choice D rationale:
Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.
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