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 ["A","E"]

Explanation

Rationale:

A. "I will take my temperature daily.": Daily temperature monitoring is essential for clients with neutropenia, as even a low-grade fever may be the only early sign of infection due to suppressed immune response. Prompt detection allows for early intervention and treatment.

B. "I will wash my toothbrush weekly.": A neutropenic client should wash or replace their toothbrush more frequently—ideally daily or after each use—to reduce the risk of bacterial growth and oral infections, which they are more vulnerable to.

C. "I will eat plenty of fresh fruits and vegetables.": Fresh, uncooked fruits and vegetables may carry harmful bacteria or fungi and should be avoided unless thoroughly washed or cooked. A neutropenic diet typically excludes raw produce to minimize infection risk.

D. "I will change my cat's litter box twice weekly.": Clients with neutropenia should avoid handling cat litter altogether, as it can harbor Toxoplasma gondii and other pathogens that pose a serious infection risk due to their weakened immune system.

E. "I will avoid crowds.": Avoiding crowds is critical for clients with neutropenia to reduce exposure to airborne and contact-transmissible pathogens, as even minor infections can become life-threatening in immunocompromised individuals.

A. "If I can keep my HbA1c less than 6.5% (less than 7%), I will be cured of diabetes." B. "I will check my blood sugar level before exercising." C. "I should have my eyes checked every 2 years." D. "I should soak my feet daily in warm, soapy water."

Correct Answer is B

Explanation

Rationale:
A. "If I can keep my HbA1c less than 6.5% (less than 7%), I will be cured of diabetes.": Maintaining an HbA1c below 7% is important for managing type 1 diabetes and reducing complications, but it does not eliminate the disease. Type 1 diabetes is a lifelong condition due to permanent loss of insulin production.

B. "I will check my blood sugar level before exercising.": Blood glucose monitoring before physical activity is essential to prevent hypoglycemia. Exercise lowers blood sugar levels, and clients with type 1 diabetes must assess their levels beforehand to determine if carbohydrate intake or insulin adjustment is needed.

C. "I should have my eyes checked every 2 years.": Clients with type 1 diabetes should have a comprehensive dilated eye exam annually, not every two years, to monitor for diabetic retinopathy, a common microvascular complication.

D. "I should soak my feet daily in warm, soapy water.": Soaking the feet is not recommended because it can lead to skin maceration and increase the risk of infection. Gentle washing and thorough drying—especially between the toes—are safer practices for foot care.

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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?

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