A nurse is planning care for a client who is in an early stage of acute kidney injury. Which of the following interventions should the nurse include in the plan?

Rationale:

A. Elevate the head of the client's bed no higher than 30°: Limiting head elevation to 30° or less reduces shear and pressure on the sacrum, which helps prevent pressure ulcer development. This position also promotes optimal circulation and skin integrity in at-risk clients.

B. Reposition the client every 4 hr: Repositioning every 4 hours is insufficient for pressure ulcer prevention. High-risk clients should be repositioned at least every 2 hours to relieve pressure and promote adequate tissue perfusion.

C. Gently massage the client's bony prominences: Massaging over bony prominences is contraindicated because it can damage fragile capillaries in already compromised skin, potentially worsening tissue injury or contributing to ulcer formation.

D. Apply cornstarch liberally over the client's at-risk skin areas: Cornstarch can promote moisture retention and friction, especially in warm environments, increasing the risk for skin breakdown. Moisture-barrier creams or silicone-based products are preferred for protecting at-risk skin.

Rationale:

A. Provide nasotracheal suctioning for the adolescent every 4 hr: Routine suctioning can increase intracranial pressure (ICP) due to stimulation of the airway. It should only be done when absolutely necessary and performed with caution in clients with elevated ICP.

B. Place the adolescent on contact precautions for 48 hr: Bacterial meningitis requires droplet precautions, not contact precautions. Droplet precautions should be maintained until 24 hours after the initiation of effective antibiotic therapy, not strictly for 48 hours.

C. Perform passive range-of-motion exercises for the adolescent prior to administering sedation: While mobility is important, performing exercises before sedation is not a priority intervention when managing increased ICP. Activity may actually raise ICP, so it should be limited during the acute phase.

D. Maintain the head of the adolescent's bed at a 20° angle: Elevating the head of the bed helps promote venous return from the brain and reduces ICP. Keeping the head midline and the bed slightly elevated is a key intervention in managing clients with increased ICP.