A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk of a friction and shear injury?
Postpone daily bed bath
Elevate the client’s head of the bed to 45 degrees
Caregiver independently slides the client up in bed
Use a mechanical lift to reposition the client every 2 hours
The Correct Answer is D
Choice A reason: Postponing daily bed bath is not appropriate for reducing the risk of a friction and shear injury. Bed bath is a hygiene measure that helps to keep the skin clean and dry and prevent infection. Friction and shear are caused by the rubbing and pulling of the skin against the bed surface, not by the bed bath itself.
Choice B reason: Elevating the client’s head of the bed to 45 degrees is not appropriate for reducing the risk of a friction and shear injury. In fact, this may increase the risk as the client may slide down the bed due to gravity and cause more friction and shear on the skin. The head of the bed should be kept at the lowest possible angle, preferably less than 30 degrees, unless contraindicated by the client’s condition.
Choice C reason: Caregiver independently slides the client up in bed is not appropriate for reducing the risk of a friction and shear injury. This may cause more damage to the skin as the caregiver may exert excessive force and drag the client’s skin along the bed surface. The caregiver should use a draw sheet or a slide board to lift and reposition the client with the help of another person.
Choice D reason: Use a mechanical lift to reposition the client every 2 hours is the most appropriate intervention for reducing the risk of a friction and shear injury. A mechanical lift is a device that helps to transfer and reposition the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the caregiver from injuring themselves by lifting the client manually. The client should be repositioned every 2 hours to relieve the pressure on the skin and prevent pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Once the tissue has necrosed from high pressure, it does not regenerate is the best explanation, because it describes the mechanism and outcome of glaucoma. Glaucoma is a condition that causes increased intraocular pressure, which damages the optic nerve and the retina, the tissues that are responsible for transmitting and processing visual information. Once these tissues are necrosed, or dead, they do not regenerate, or grow back, resulting in irreversible vision loss.
Choice B reason: Glaucoma always leads to permanent blindness is not a good explanation, because it is inaccurate and pessimistic. Glaucoma does not always lead to permanent blindness, but rather to progressive vision loss that can be prevented or slowed down with early diagnosis and treatment. Glaucoma can cause peripheral vision loss, tunnel vision, or blind spots, but not necessarily complete blindness.
Choice C reason: Once retinal detachment occurs, it does not return to its normal state is not a good explanation, because it is irrelevant and misleading. Retinal detachment is a condition that occurs when the retina separates from the underlying layer of blood vessels, which can cause vision loss or blindness. However, retinal detachment is not caused by glaucoma, nor is it a common complication of glaucoma. Retinal detachment can sometimes be repaired with surgery, depending on the extent and duration of the detachment.
Choice D reason: Once bacterial infection has caused damage, the tissue does not regenerate is not a good explanation, because it is incorrect and confusing. Bacterial infection is not a cause or a consequence of glaucoma, but rather a separate condition that can affect the eye. Bacterial infection can cause inflammation, pain, discharge, or redness in the eye, but not necessarily vision loss or tissue necrosis. Bacterial infection can usually be treated with antibiotics, which can prevent or reverse the damage.
Correct Answer is B
Explanation
Choice A reason: Stage 1 is a wound that involves only the epidermis, the outermost layer of the skin. It appears as a nonblanchable redness, warmth, or hardness on intact skin. It does not have any breakage or ulceration of the skin.
Choice B reason: Stage 2 is a wound that involves the epidermis and the dermis, the second layer of the skin. It appears as a shallow, open, reddened ulcer with a partialthickness loss of skin. It may have some serous exudate, but no slough or eschar. It may also present as a blister or abrasion.
Choice C reason: Stage 3 is a wound that involves the epidermis, the dermis, and the subcutaneous tissue, the third layer of the skin. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin. It may have some slough or eschar, but no exposed bone, tendon, or muscle. It may also have tunneling or undermining of the wound edges.
Choice D reason: Stage 4 is a wound that involves the epidermis, the dermis, the subcutaneous tissue, and the underlying structures, such as bone, tendon, or muscle. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin and tissue. It has exposed bone, tendon, or muscle, which may be visible or palpable. It may also have slough, eschar, necrosis, infection, or osteomyelitis.
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