A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Reposition the client every 2 hours.

Massage the skin over the client's bony prominences.

Position the client in high Fowler's.

Apply cornstarch to keep sensitive skin areas dry.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Repositioning the client every 2 hours is a standard preventive measure to reduce the risk of pressure ulcers. Frequent repositioning helps alleviate pressure on vulnerable areas, improving circulation and preventing skin breakdown. This intervention is widely recommended to maintain skin integrity in at-risk clients.

Choice B reason:

Massaging the skin over bony prominences can cause tissue damage and increase the risk of pressure ulcers. Instead of promoting circulation, it can exacerbate skin breakdown and should be avoided as a preventive measure.

Choice C reason:

Positioning the client in high Fowler's is not specifically related to preventing pressure ulcers. High Fowler's position can help with respiratory issues but does not address pressure redistribution needed to prevent skin breakdown in vulnerable areas.

Choice D reason:

Applying cornstarch to keep sensitive skin areas dry is not an evidence-based intervention for pressure ulcer prevention. Cornstarch can create friction and irritation, potentially worsening skin integrity rather than preserving it.

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Correct Answer is A

Explanation

Choice A reason:

Repositioning the client at least every 2 hours is a standard intervention to prevent further pressure ulcers and promote healing of existing ones. This practice helps alleviate pressure on vulnerable areas, improving blood circulation and reducing the risk of tissue breakdown.

Choice B reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for pressure ulcers as it can damage healthy tissue and delay wound healing. Alternative wound cleaning solutions that are less harsh should be used to promote a more conducive healing environment.

Choice C reason:

Massaging reddened areas with dressing changes is contraindicated as it can exacerbate tissue damage and increase the risk of further ulceration. Gentle handling and appropriate wound care are essential to prevent additional harm to the affected areas.

Choice D reason:

Applying a heat lamp twice a day is not a standard or recommended practice for treating pressure ulcers. Heat can increase the risk of burns and further tissue damage. Proper wound care, including maintaining a clean and moist wound environment, is more effective for healing.

Correct Answer is ["50"]

Explanation

Step 1: Determine the amount of medication prescribed.
The client is prescribed 250 mg of phenytoin.

Step 2: Identify the concentration of the solution available.
The concentration is 25 mg per 5 mL.

Step 3: Calculate how many milligrams are in 1 mL of the solution.
25 ÷ 5 = 5 mg per 1 mL.

Step 4: Determine how many mL are needed to administer 250 mg.
250 ÷ 5 = 50 mL.

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A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

Correct Answer is ["50"]

Explanation

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