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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3"]
Explanation
Given:
Ordered dose of Furosemide: 30 mg
Concentration of Furosemide: 10 mg/mL
Step 1: Set up the proportion:
Desired dose (mg) / Volume to administer (mL) = Concentration (mg/mL)
Step 2: Substitute the values:
30 mg / Volume = 10 mg/mL
Step 3: Solve for the unknown volume:
Volume = 30 mg / (10 mg/mL)
Volume = 30 mg x (1 mL / 10 mg)
Volume = 3 mL
Correct Answer is A
Explanation
A) Provide a dedicated area for the nurse to prepare medications:
Having a dedicated, quiet area for preparing medications is crucial for reducing the risk of medication errors. A designated space minimizes distractions, ensures proper organization, and allows the nurse to focus on the task at hand, which can help prevent mistakes. It also supports a more organized environment where medications can be checked for accuracy, labels can be read carefully, and correct dosages can be administered. This is the best practice to reduce medication errors.
B) Wait to document medications given to clients until the end of a shift:
Delaying the documentation of medications until the end of a shift increases the risk of forgetting to document or making errors. Medications should be documented immediately after administration to ensure accuracy and prevent omissions. Immediate documentation also provides real-time updates on the client's medication history and avoids any discrepancies between what was actually administered and what is recorded.
C) Remove medications from automatic dispensing systems before they are reviewed by pharmacists:
Removing medications from automatic dispensing systems before they are reviewed by pharmacists increases the risk of errors. Medications should be reviewed by the pharmacist to ensure proper drug selection, dosage, and appropriateness for the patient's condition. Pharmacists play an essential role in medication safety, and bypassing their review increases the likelihood of incorrect medication administration, potentially leading to harmful consequences.
D) Prepare medications for multiple clients at the same time:
Preparing medications for multiple clients simultaneously is risky and can lead to confusion and errors. Nurses should focus on preparing medications for one patient at a time to ensure that the correct medication and dosage are administered to the correct person. This practice reduces the likelihood of mixing up medications or administering the wrong drug or dosage.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.