A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

Maintain the head of the bed greater than 45°.

Place a donut-shaped cushion under the client’s sacrum.

Massage bony prominences three times daily.

Apply moisturizer to damp skin after bathing.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk.

B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution.

C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma.

D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Give each screw a quarter turn daily using the wrench provided: Clients should never adjust or tighten the halo device screws themselves. Only trained medical professionals should handle adjustments to avoid misalignment or injury to the cervical spine.

B. Apply powder liberally under the chest portion of the halo fixator device: Powder can cake and irritate the skin or lead to moisture buildup, increasing the risk of skin breakdown or infection. The skin under the vest should be kept clean and dry, not powdered.

C. Avoid the use of straws when drinking liquids: Clients can safely use straws to drink fluids while wearing a halo device. There is no contraindication for using a straw, and it may actually make drinking easier.

D. Place a small pillow under the head while lying supine: Using a small pillow supports neck alignment and promotes comfort without compromising the stability of the halo device. This is an appropriate and recommended practice during rest.

A. Oral temperature of 37.2° C (99° F) B. Clear drainage on the dressings C. Drain output 75 mL in 4 hr D. Decreased bowel sounds in all quadrants of the abdomen

Correct Answer is B

Explanation

Rationale:
A. Oral temperature of 37.2° C (99° F): This is a normal postoperative temperature and does not indicate infection or any other complication. Mild elevations in temperature are expected after surgery.

B. Clear drainage on the dressings: Clear drainage, particularly if it is watery and not tinged with blood, may indicate cerebrospinal fluid (CSF) leakage. This is a serious complication of spinal surgery and requires immediate evaluation to prevent infection and further neurological issues.

C. Drain output 75 mL in 4 hr: This amount of drainage is within normal limits for the early postoperative period, depending on the surgeon's parameters. It is not inherently concerning unless it becomes excessive or has abnormal characteristics.

D. Decreased bowel sounds in all quadrants of the abdomen: Decreased bowel activity is common after surgery due to anesthesia and immobility. It is expected in the immediate postoperative period and not necessarily a sign of a complication unless prolonged.

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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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