A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Encourage client fluid intake of 2,500 mL daily.

Moisturize dry skin areas on the client every other day.

Place a dehumidifier in the client's room.

Apply a donut ring pillow under the client's sacral area.

Answer and Explanation

The Correct Answer is A

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

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Correct Answer is A

Explanation

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

A. Dependent edema B. Pericardial friction rub C. Paradoxical pulse D. Substernal chest pain

Correct Answer is D

Explanation

A. Dependent edema may be present in pericarditis but is not typically the priority finding unless it indicates worsening heart failure.

B. Pericardial friction rub is a classic finding in pericarditis but is not the priority unless it indicates cardiac tamponade, which is a medical emergency.

C. Paradoxical pulse may occur in pericarditis but is not necessarily the priority finding unless it is severe and indicative of cardiac tamponade.

D. Substernal chest pain is the priority finding in pericarditis as it indicates inflammation of the pericardium, which can lead to complications such as myocardial infarction or cardiac

tamponade. Prompt intervention is necessary to alleviate pain and prevent complications.

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A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Correct Answer is D

Explanation

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