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

Keep the head of the client’s bed elevated to 45

Provide the client with a high-calorie diet.

Massage the client’s bony prominences.

Reposition the client every 4 hr.

Answer and Explanation

The Correct Answer is B

A) Keep the head of the client’s bed elevated to 45 degrees:
Elevating the head of the bed to 45 degrees can actually increase the risk of pressure injuries, particularly in clients who are already at risk. This position can cause shearing forces and increase pressure on areas such as the sacrum, heels, and hips, making it more likely for pressure ulcers to develop.

B) Provide the client with a high-calorie diet:
A high-calorie diet is important for clients at risk of pressure injuries because adequate nutrition supports skin integrity and wound healing. Clients at risk for pressure injuries often have compromised nutritional status, and providing sufficient calories, protein, and other nutrients helps improve tissue regeneration and resilience. A high-calorie, high-protein diet helps prevent further breakdown of the skin and supports the healing process for any existing wounds.

C) Massage the client’s bony prominences:
Massaging bony prominences, such as the heels, elbows, and sacrum, is not recommended because it can cause tissue damage and increase the risk of pressure injury. Instead, the focus should be on minimizing pressure on these areas and using appropriate methods to redistribute pressure, such as repositioning the client or using pressure-relieving devices.

D) Reposition the client every 4 hours:
Repositioning the client every 4 hours may not be frequent enough for those at high risk for pressure injuries. For individuals who are immobile or at high risk, repositioning should typically occur at least every 2 hours to alleviate pressure on vulnerable areas of the body.

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Correct Answer is A

Explanation

A) Researcher:
The nurse is gathering evidence-based practice (EBP) on catheter-associated urinary tract infections (CAUTI), which involves systematically collecting, analyzing, and reviewing existing studies or guidelines to inform clinical practice. This is the role of the researcher in EBP. Nurses in this role contribute to improving patient outcomes by identifying best practices, assessing existing evidence, and implementing findings to reduce complications, such as CAUTIs.

B) Nurse manager:
While a nurse manager may oversee quality improvement projects, staffing, and other operational aspects of nursing care, they are not typically the ones actively gathering evidence-based data themselves. Nurse managers may utilize the findings from research but are not directly involved in the research process unless leading specific studies.
C) Case manager:
A case manager primarily coordinates care for individual patients, ensuring they receive the appropriate resources and follow-up care. They help manage the continuity of care across different settings but do not focus on gathering or researching evidence for clinical practices. Their role is more focused on patient outcomes and care delivery rather than generating evidence.

D) Educator:
While an educator might be involved in teaching staff or patients about preventing CAUTI, the role described in the question specifically refers to gathering evidence-based practice information. Educators may use research findings in their teaching, but gathering evidence is a distinct activity that fits the role of the researcher in EBP.

A. The client who has a nasogastric (NG) tube to suction B. The client who has a chest tube to water seal C. The client who has an indwelling urinary catheter to gravity drainage D. The client who has a tracheostomy tube attached to humidified oxygen

Correct Answer is A

Explanation

A) The client who has a nasogastric (NG) tube to suction:
A nasogastric (NG) tube that is used for suction can lead to the loss of gastric fluids, which are rich in potassium. Prolonged suctioning can cause the client to lose significant amounts of potassium, putting them at risk for hypokalemia. Potassium is an essential electrolyte that is vital for proper muscle and nerve function, and its loss can result in symptoms such as weakness, arrhythmias, and fatigue.

B) The client who has a chest tube to water seal:
A chest tube to water seal is used to drain air or fluid from the pleural space, typically following surgery or trauma. While chest tube drainage can lead to fluid loss, it is not directly associated with significant electrolyte imbalances like hypokalemia. The primary concern with chest tubes is fluid balance and preventing infection, but it does not specifically cause potassium loss unless there are other contributing factors, such as excessive diuresis or vomiting.

C) The client who has an indwelling urinary catheter to gravity drainage:
An indwelling urinary catheter primarily allows for the drainage of urine, and while it may contribute to fluid and electrolyte loss (especially if there is excessive urination or diuresis), it is not directly linked to hypokalemia unless the client is receiving medications (e.g., diuretics) that cause potassium loss through urine. The catheter itself does not significantly increase the risk of hypokalemia unless other factors are involved.

D) The client who has a tracheostomy tube attached to humidified oxygen:
A tracheostomy tube attached to humidified oxygen helps with respiratory support and does not directly affect potassium levels. The primary concern with tracheostomies is airway management, preventing infection, and ensuring proper oxygenation. It is not associated with electrolyte imbalances such as hypokalemia. However, if the client experiences issues such as excessive fluid loss through respiratory secretions or complications like infection, it could indirectly affect electrolyte levels, but it is not a direct cause of hypokalemia.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering evidence based practice on catheter associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?

Correct Answer is A

Explanation

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Correct Answer is A

Explanation

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