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) Safety needs:
In Maslow's hierarchy of needs, safety needs are the second level, after physiological needs, and include the need for security and protection from harm. In this scenario, the client’s concern about where to hide their cellphone during the procedure reflects anxiety related to the potential loss or theft of personal property, which relates to safety and security. By offering to lock the cellphone in a secure area, the nurse is addressing the client's need for safety and reassurance about their belongings while undergoing a medical procedure.

B) Esteem needs:
Esteem needs are related to feelings of self-worth, accomplishment, and respect from others. While a person’s sense of esteem can be affected by how others treat their belongings, this particular situation does not relate to the client seeking recognition or respect. The client’s anxiety about where to place the cellphone is more about feeling secure and protected, rather than about esteem or recognition from others.

C) Love and belonging needs:
Love and belonging needs are associated with the need for interpersonal relationships, affection, and social connections. While the nurse’s interaction with the client may help foster a sense of comfort and connection, the concern about the cellphone does not stem from a need for social support or relationships. Instead, it is related to safety and security.

D) Physiological needs:
Physiological needs represent the most basic level of Maslow's hierarchy and include things like air, food, water, and shelter. Although the client is preparing for a medical procedure, their concern about the cellphone does not fall under this category. The focus here is on the safety of the client’s belongings, which is a higher-level need than basic physiological survival.

A. Assist the client into a standing position B. Check the blood pressure with the client in a supine position. C. Determine the client's blood pressure 1 min after each position change. D. Place the client in a sitting position

Correct Answer is B

Explanation

A) Assist the client into a standing position:
While assisting the client into a standing position is necessary for assessing orthostatic hypotension, it should not be the first action. The nurse needs baseline measurements of the client's blood pressure before making any position changes. This ensures that the changes in blood pressure can be accurately attributed to the positional changes, rather than being affected by the initial standing position.

B) Check the blood pressure with the client in a supine position:
The first step in assessing for orthostatic hypotension is to take a baseline blood pressure while the client is lying flat in the supine position. This provides a reference point for comparison when the client changes positions (to sitting and then standing). This helps to detect significant drops in blood pressure when transitioning to an upright position.

C) Determine the client's blood pressure 1 minute after each position change:
While it is important to measure blood pressure after each position change, this action should occur after baseline blood pressure has been taken while the client is in the supine position. Orthostatic hypotension is assessed by measuring blood pressure in three positions: supine, sitting, and standing.

D) Place the client in a sitting position:
Placing the client in a sitting position is a necessary part of the orthostatic hypotension assessment, but it is not the first step. The nurse must first measure the blood pressure while the client is lying down (supine) to establish a baseline for comparison with the blood pressure readings taken after sitting and standing.

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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

Correct Answer is A

Explanation

A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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