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:

Placing the patient in a lateral position (recovery position) is critical to maintain an open airway and prevent aspiration, especially in a client who is not responding to verbal stimuli. This position helps ensure that the airway remains clear and reduces the risk of aspiration if the client vomits.

Choice B reason:

Applying a warm blanket is important for maintaining the client’s body temperature but is not the immediate priority when the client is unresponsive. Ensuring airway patency takes precedence.

Choice C reason:

Comparing and contrasting peripheral pulses is part of the assessment process but is not the first priority. Ensuring the client's airway and breathing are secure is more urgent.

Choice D reason:

Assessing dressings is necessary to monitor for bleeding or other complications but is not as immediate as ensuring the client’s airway is clear and protected.

A. Restrain the client. B. Move objects away from the client. C. Place the client on his back. D. Insert a padded tongue blade into the client’s mouth.

Correct Answer is B

Explanation

Choice A reason:

Restraint during a seizure can lead to injury. It is important to allow the seizure to run its course while ensuring the client is safe from harm. The priority is to protect the client from injury without restraining them, as this can cause fractures or muscle damage.

Choice B reason:

Moving objects away from the client helps prevent injury during a seizure. Clearing the area ensures that the client does not hit anything during the convulsions, reducing the risk of injury. This is a safe and effective measure to protect the client.

Choice C reason:

Placing the client on their back is not recommended during a seizure as it can increase the risk of aspiration if the client vomits. Instead, the client should be turned onto their side (recovery position) to keep the airway clear and prevent choking.

Choice D reason:

Inserting a padded tongue blade into the client’s mouth is outdated and dangerous. It can cause dental damage or block the airway. There is also a risk of injury to both the client and the person attempting to insert the object. It is no longer recommended.

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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

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