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 B

Explanation

A. The ropes are in the center of the wheel grooves.

Having the ropes in the center of the wheel grooves is appropriate and ensures proper alignment within the pulley system. This is not a problem that needs correction.

B. The weights rest against the foot of the bed.

This is the correct choice for correction. Allowing the weights to rest against the foot of the bed can alter the amount of force applied to the skeletal structures and compromise the effectiveness of the traction. The weights should hang freely and move within the pulley system.

C. The weights are equal on each side.

Having equal weights on each side is generally appropriate and helps maintain proper balance in the traction system. This is not a problem that needs correction.

D. The ropes attach securely to the pin.

Secure attachment of the ropes to the pin is essential for maintaining proper traction. This is not a problem that needs correction if the attachment is secure.

A. Offer to request a prescription for an indwelling urinary catheter. B. Keep a night light on in the client’s room. C. Limit the client’s fluid intake in the evening. D. Put the side rails up and tell the client to call for assistance to the bathroom.

Correct Answer is B

Explanation

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.

B. Keep a night light on in the client’s room.

This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.

C. Limit the client’s fluid intake in the evening.

Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.

D. Put the side rails up and tell the client to call for assistance to the bathroom.

While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.

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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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Naxlex Comprehensive Predictor Exams

A client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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