A nurse is caring for an adult client who requires nasopharyngeal suctioning. Which of the following actions should the nurse take?

A. Reposition the client every 3 hr: This is insufficient. The standard of care for a client at risk is repositioning at least every 2 hours while in bed and every 1 hour while sitting in a chair to ensure adequate blood flow to compressed tissues.

B. Place the client on a donut-shaped cushion: A donut-shaped cushion is not recommended for preventing pressure ulcers. It can increase pressure on the tissue, leading to further complications. A more effective intervention is use of pressure-redistribution surfaces.

C. Elevate the head of the bed to 45°: Elevating the head of the bed can increase pressure on the sacral area and can be uncomfortable for clients with mobility and incontinence issues. The head of the bed should be elevated only when necessary for breathing or comfort, not as a routine practice.

D. Request a consult with a registered dietitian: The client has decreased intake and may be at risk for malnutrition or dehydration. A dietitian’s input is essential to assess nutritional needs, especially for a client with diabetes and decreased mobility, to ensure proper healing and management.

E. Provide a support pressure-redistribution surface: A support pressure-redistribution surface is crucial for this client to reduce the risk of pressure ulcers. These surfaces help alleviate pressure on bony prominences and distribute the body weight evenly to prevent tissue damage.

F. Perform a skin risk assessment weekly: Skin risk assessments should be done more frequently than weekly, especially for a client with decreased mobility, incontinence, and diabetes. Daily or at least twice-weekly assessments are needed to monitor for early signs of skin breakdown.

G. Use a moisture barrier ointment after cleaning the client's skin: Using a moisture barrier ointment is essential for protecting the skin, especially since the client has urinary and fecal incontinence. This will help prevent skin irritation and breakdown caused by exposure to moisture.

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.