A nurse is developing a plan of care for a client who is immobile and at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan?

Apply moisturizing lotion to the client's skin after bathing.

Massage the client's bony prominences twice per shift.

Maintain the head of the client's bed at a 45° angle.

Place the client in contact isolation.

Answer and Explanation

The Correct Answer is A

Rationale:

A. This option is correct because applying moisturizing lotion after bathing helps maintain skin integrity, prevents dryness and cracking, and reduces the risk of pressure injuries. Proper skin care is a key preventive measure for clients who are immobile.

B. This option is incorrect because massaging bony prominences is not recommended; it can actually cause tissue damage and increase the risk of pressure injury. Instead, gentle repositioning and pressure-relief techniques should be used.

C. This option is incorrect because maintaining the head of the bed at a 45° angle increases pressure on the sacral area, heightening the risk for pressure injuries. The head of the bed should generally be kept at 30° or less when possible to reduce shear and pressure on bony prominences.

D. This option is incorrect because contact isolation is not a preventive measure for pressure injuries. It is used for clients with infectious conditions to prevent transmission, not for immobility-related skin protection.

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Correct Answer is C

Explanation

Rationale:

A. This option is incorrect because a comatose client with severe head trauma may have a poor prognosis and is considered expectant in a mass casualty scenario. Resources are typically allocated to clients with a higher likelihood of survival.

B. This option is incorrect because a compound fracture of the forearm is serious but not immediately life-threatening. This client can safely wait for treatment without the risk of rapid deterioration.

C. This option is correct because a client with a severed lower extremity is at high risk for hemorrhagic shock and requires immediate intervention to control bleeding and stabilize the patient. In mass casualty triage, clients with life-threatening but potentially survivable injuries are prioritized for transport to acute care facilities.

D. This option is incorrect because multiple abrasions are minor injuries that are not life-threatening. These clients are considered "green tag" or walking wounded and are the lowest priority for immediate transport.

A. Social worker B. Speech-language pathologist C. Respiratory therapist D. Occupational therapist

Correct Answer is D

Explanation

Rationale:

A. This option is incorrect because a social worker assists clients with psychosocial needs, community resources, or discharge planning. While helpful in addressing social or environmental concerns, a social worker does not provide direct interventions for physical limitations related to bathing or daily living activities.

B. This option is incorrect because a speech-language pathologist evaluates and treats communication and swallowing disorders. Difficulty with bathing is not within their scope of practice.

C. This option is incorrect because a respiratory therapist focuses on managing clients’ respiratory needs, such as oxygen therapy, ventilator management, and breathing exercises. They do not assist with activities of daily living like bathing.

D. This option is correct because an occupational therapist (OT) specializes in helping clients regain independence in activities of daily living (ADLs), including bathing, dressing, and grooming. The OT can assess the client’s functional abilities, recommend adaptive equipment, and provide strategies to safely perform self-care after a fall or injury.

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A nurse is developing a plan of care for a client who is immobile and at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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