A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
Massage the client’s bony prominences.
Keep the head of the bed elevated.
Reposition the client at least every 2 hr.
Keep the client’s skin moist.
The Correct Answer is C
A. Massage the client’s bony prominences:
Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.
B. Keep the head of the bed elevated:
While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.
C. Reposition the client at least every 2 hr:
Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.
D. Keep the client’s skin moist:
While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “You should avoid the use of cell phones after the pacemaker is placed.”
This statement is not accurate. In general, the use of cell phones is considered safe for individuals with pacemakers. However, it is recommended to keep the phone on the opposite side of the pacemaker to minimize any potential interference.
B. “Swelling and redness of the operative site are normal findings for the first two days following the
procedure.”
This statement is partially accurate. Swelling and redness at the operative site can be expected immediately after the procedure. However, if these signs persist or worsen after the first two days, it may indicate a potential issue, and the healthcare provider should be notified.
C. “You will need to limit movement of the arm on the side of the pacemaker.”
This statement is accurate. Limiting movement of the arm on the side of the pacemaker is a standard precaution to prevent dislodgement of the leads and allow proper embedding of the pacemaker leads into the surrounding tissues.
D. “Hiccups following pacemaker placement are an expected response.”
This statement is not accurate. Hiccups are not typically associated with pacemaker placement. If the client experiences unexpected symptoms, such as hiccups, it is important to report them to the healthcare provider for further evaluation.
Correct Answer is B
Explanation
A. Reduction of the fracture:
Buck's traction is not primarily intended for the reduction (realignment) of the fractured bones. While it may help maintain proper alignment, the primary goal is to provide temporary immobilization and relieve muscle spasms until more definitive treatment, such as surgery, can be performed.
B. Relief from muscle spasms:
This is the correct answer. Buck's traction is commonly used to alleviate muscle spasms associated with hip fractures. The traction force helps to relax the muscles, reduce pain, and maintain the alignment of the fractured bones.
C. Alignment of the pins:
Buck's traction does not involve the insertion of pins into the bone. It uses a boot attached to the leg, and the traction force is applied externally to the limb to achieve the desired therapeutic effects.
D. Support for moving the extremity:
Buck's traction is not intended to support active movement of the extremity. Instead, it provides temporary immobilization to prevent further injury and facilitate the healing process before more definitive interventions, such as surgery, are undertaken.
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