A nurse is caring for a client who is immobile and developing skin breakdown. Which of the following actions should the nurse take?
Bathe the client with soap and hot water.
Massage bony prominences four times daily.
Keep the head of the client's bed at 30° or less.
Slide the client up in bed every 2 hr.
The Correct Answer is C
A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.
B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.
C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.
D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the housekeeping department: Housekeeping is not the appropriate department to address a malfunctioning infusion pump. The nurse should take immediate action to address the malfunction, such as replacing the pump.
B. Replace the infusion pump: If the infusion pump is malfunctioning, the nurse should replace it with a functional one to ensure that the client's infusion continues safely. This is the most appropriate and immediate action to take in response to a malfunction.
C. Check the expiration date on the safety inspection sticker: While it is important to ensure equipment is regularly inspected, checking the expiration date on the safety inspection sticker does not address an immediate malfunction. The priority should be replacing the pump to prevent disruption of the IV infusion.
D. Plug the infusion pump into a grounded outlet: While ensuring that the pump is plugged into a grounded outlet is important for electrical safety, this does not directly resolve the issue if the pump itself is malfunctioning.
Correct Answer is D
Explanation
A. A middle adult experiences physical changes: While physical changes are a normal part of aging, they do not necessarily indicate a change in the family system. Stressors affecting the family dynamic are more evident in relational shifts or roles.
B. A young adult develops a close, personal relationship: This is a developmental milestone for a young adult and does not suggest a change in the family system. Relationships are important, but this behavior is not typically a sign of stressors impacting the family structure.
C. A young adult focuses on their career: Career development is a normal developmental task for a young adult and may not indicate a change in the family system. It is a personal growth milestone rather than a response to family stress.
D. A middle adult assumes their parent's responsibilities: This behavior, known as the "sandwich generation" phenomenon, occurs when a middle adult takes on caregiving roles for aging parents while possibly still caring for their own children. This shift in roles is a significant indicator of stressors affecting the family system.
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