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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: The recommended hepatitis vaccine series does not consist of four vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends a 3-dose series for most individuals, which includes doses at birth, 1-2 months, and 6-18 months.
Choice B Rationale: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through exposure to infectious blood, semen, and other body fluids. Transmission can occur through direct contact with blood or body fluids of an infected person, unprotected sex, sharing needles, or from mother to child at birth.
Choice C Rationale: While chronic hepatitis C has been associated with an increased risk of developing renal cell carcinoma, the evidence linking chronic hepatitis B with renal cell cancer is less clear. Some studies suggest a potential association, but it is not established as a common complication.
Choice D Rationale: Individuals with a history of hepatitis B or C are generally ineligible to donate blood. This is due to the risk of bloodborne transmission of these viruses. Even if the individual has recovered or been cured of hepatitis C, they are still barred from donating blood or plasma.
Correct Answer is B
Explanation
A. A flexible activity schedule may increase overstimulation; structured activities with set limits are more appropriate for clients in acute mania.
B. Clients experiencing acute mania often have increased energy expenditure and may neglect meals; providing high-calorie nutritional supplements helps prevent weight loss and maintains adequate nutrition.
C. Eating alone may increase the risk of inadequate intake due to distraction or hyperactivity; supervised or structured meal times are safer.
D. Allowing unrestricted choice of clothing may lead to inappropriate or disorganized attire; guidance is needed to maintain safety and appropriate appearance.
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