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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Check that the client lifts the walker and then places it down in front of her.

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

B. Walk in front of the client to guide her in moving the walker.

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

D. Make sure that the upper bar of the walker is level with the client’s waist.

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

A. Yogurt B. Oranges C. Turnips D. Roast beef

Correct Answer is D

Explanation

A. Yogurt:

Yogurt is not a significant source of iron. While yogurt provides various nutritional benefits, it is not considered an iron-rich food.

B. Oranges:

Oranges are a good source of vitamin C, which enhances the absorption of non-heme iron from plant-based foods. However, oranges themselves do not contain substantial amounts of iron. The combination of vitamin C-rich foods with iron-rich foods can be beneficial for iron absorption.

C. Turnips:

Turnips are a vegetable that, while nutritious, is not particularly high in iron. Additionally, the iron in plant-based foods like turnips is non-heme iron, which is less easily absorbed by the body compared to heme iron found in animal products.

D. Roast beef:

Roast beef is a good source of heme iron, which is more easily absorbed by the body. Red meat, such as roast beef, is a valuable dietary source of iron, especially for individuals with iron deficiency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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