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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Education may influence the communication process to a significant extent as an interpersonal variable.
B. Time can affect communication in terms of available time for interaction, but it is not specifically related to interpersonal variables.
C. Perception refers to how individuals interpret and make sense of information. It is a key interpersonal variable that can influence how a message is received and understood.
D. Gender can be an interpersonal variable that affects communication. Different genders may have different communication styles and preferences.
E. Feedback is not considered an interpersonl ariation that can affect communication
Correct Answer is A
Explanation
A. Having the client wear a mask is the most appropriate precaution for safely
transporting a client with active pulmonary tuberculosis (TB) who requires airborne precautions. This helps contain potentially infectious respiratory droplets.
B. Asking the x-ray technician to come to the client's room to obtain a portable X-ray is a reasonable option, but it may not always be feasible depending on the facility's resources and policies.
C. Notifying the x-ray department that the client requires airborne precautions is an important step, but it is not sufficient on its own. The client should also wear a mask during transport.
D. Wearing a filtration mask and gloves during transport is not enough. The nurse should also ensure that the client is wearing a mask to contain respiratory secretions.
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