A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
Elevate the head of the bed no more than 45°.
Use a transfer device to lift the client up in bed.
Massage the skin over the client's bony prominences.
Apply cornstarch to keep sensitive skin areas dry.
The Correct Answer is B
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.
B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.
C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.
D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.
E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.
Correct Answer is ["A","B","D","E"]
Explanation
A. Wearing a mask helps protect against the transmission of airborne particles, which is important for preventing the spread of tuberculosis.
B. Wearing a gown can provide an additional barrier to prevent the transmission of infectious material.
C. Disposing sharps here is not directly related to tuberculosis precautions. This statement is more relevant for a sharps disposal container.
D. Wearing gloves is important to prevent direct contact with potentially contaminated surfaces.
E. Hand hygiene is crucial for infection control and should be emphasized for anyone entering or exiting the room of a client in isolation.
F. "Radiation inside" is not applicable to the isolation precautions for tuberculosis. This statement is unrelated to tuberculosis precautions and may cause confusion.
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