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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Massage over erythematous bony prominences.

Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface.

Implement a turning schedule every 4 hours.

Keep the client's skin dry with powder.

Answer and Explanation

Correct Answer : B,C

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

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Correct Answer is C

Explanation

Choice A reason:
Resuming sexual intercourse in 2 to 3 weeks may not be appropriate for all patients after such a major surgery. The recovery time can vary based on individual factors, including the extent of the surgery and the patient's overall health. It's essential for patients to follow their healthcare provider's specific recommendations, which typically involve waiting until after the postoperative check-up, usually around 6 weeks, to ensure proper healing.

Choice B reason:
Increased vaginal drainage typically occurring 5 days following surgery could be a sign of infection or other complications. Normal postoperative discharge should gradually decrease over time. If a patient experiences increased drainage, especially if it's foul-smelling or accompanied by fever, they should contact their healthcare provider immediately.

Choice C reason:
After a total abdominal hysterectomy and bilateral salpingo-oophorectomy, patients may experience vaginal dryness due to decreased estrogen levels. Using artificial lubricants can help alleviate symptoms of itching and dryness, making this an appropriate instruction for postoperative care.

Choice D reason:
A Papanicolaou (Pap) test is not typically required every 6 months after a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer unless the surgery was performed as treatment for cervical cancer or serious pre-cancer. For those who had the procedure due to benign conditions, further Pap tests are generally not necessary.

A. Inspect the mouth for signs of inhalation injuries. B. Insert an indwelling urinary catheter. C. Draw blood for a complete blood cell (CBC) count. D. Administer intravenous pain medication.

Correct Answer is A

Explanation

Choice A reason:
In the case of burns to the face and chest, assessing for inhalation injuries is critical due to the potential for airway compromise. Inhalation injuries can lead to significant respiratory distress and are considered a high priority in burn care. Inspecting the mouth for soot, burns, or edema can provide immediate information about the potential for respiratory complications, which can be life-threatening.

Choice B reason:
While monitoring urine output is important in burn patients for assessing fluid balance and kidney function, it is not the immediate priority. The insertion of an indwelling urinary catheter can be performed after stabilizing the airway and ensuring the patient is breathing adequately.

Choice C reason:
A CBC count is important for evaluating the patient's overall health status and can indicate the presence of infection or anemia. However, it is not the first action to take in the emergency setting where immediate life-saving interventions are prioritized.

Choice D reason:
Administering intravenous pain medication is important for patient comfort and can facilitate further care, but it is not the first priority. The initial focus should be on life-saving measures such as securing the airway and assessing for inhalation injuries.

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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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