A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?
30° lateral.
Lateral semi-prone recumbent.
Supine.
45° supported Fowler's.
The Correct Answer is A
The correct answer is choice A. 30° lateral.
Choice A rationale:
The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.
Choice B rationale:
The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.
Choice C rationale:
The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.
Choice D rationale:
The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Dysrhythmia refers to irregular heart rhythms and is not associated with the carotid artery. It involves issues with the heart's electrical conduction system.
Choice B rationale:
A cardiac murmur is an abnormal sound heard during the heartbeat cycle, usually indicating turbulent blood flow across heart valves. It's not directly related to the carotid artery.
Choice C rationale:
Hypotension refers to low blood pressure, which might impact blood flow through the carotid artery but wouldn't directly cause the sound known as a bruit.
Choice D rationale:
A bruit heard while auscultating the carotid artery suggests a narrowed arterial lumen. A bruit is a whooshing or blowing sound caused by turbulent blood flow due to arterial narrowing or blockage.
Correct Answer is C
Explanation
Choice A rationale:
Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.
Choice B rationale:
Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.
Choice C rationale:
Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.
Choice D rationale:
Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.
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