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. “Use sugar-free gum if you experience a metallic taste in your mouth.”

This is the appropriate choice. Chemotherapy can cause a metallic taste in the mouth, and using sugar-free gum or candies can help alleviate this taste disturbance.

B. “Drink fluids at mealtime to prevent early satiety.”

This statement is not advisable. Drinking fluids at mealtime may lead to early satiety, making it challenging for the client to consume adequate nutrition. It is generally recommended to drink fluids between meals.

C. “Foods that are higher in fat can help nausea.”

This statement is not accurate. High-fat foods may exacerbate nausea for some individuals undergoing chemotherapy. The focus during periods of nausea is often on easily digestible, low-fat, and bland foods.

D. “Raw fruits and vegetables will be easier for your body to digest.”

This statement is not accurate. Raw fruits and vegetables may be harder to digest, and during chemotherapy, the digestive system can be sensitive. It is generally recommended to choose cooked or processed fruits and vegetables for easier digestion.

A. “Eating yogurt can help decrease gas odor that I have.” B. “I should eliminate pasta from my diet so that I don’t have as many loose stools.” C. “My largest meal of the day should be in the evening.” D. “Carbonated beverages can help control odor.”

Correct Answer is A

Explanation

A. "Eating yogurt can help decrease gas odor that I have."
This is the correct choice. Yogurt contains probiotics, which can contribute to a healthy balance of bacteria in the digestive system, potentially reducing gas odor associated with a colostomy.

B. "I should eliminate pasta from my diet so that I don’t have as many loose stools."
This statement is incorrect. Pasta, as a general rule, is not associated with causing loose stools. Dietary adjustments should be individualized, and specific triggers for loose stools vary among individuals.

C. "My largest meal of the day should be in the evening."
While meal timing can vary based on personal preferences and lifestyle, there is no strict rule that the largest meal must be in the evening. It depends on individual habits and dietary needs.

D. "Carbonated beverages can help control odor."
This statement is incorrect. Carbonated beverages are not typically associated with controlling odor related to a colostomy. In fact, they may contribute to increased gas production, potentially exacerbating odor issues.

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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?

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