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.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.
B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.
C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.
D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.
Correct Answer is A
Explanation
A.
A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.
B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.
C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.
D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.
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