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 C

Explanation

A. Provide a diet high in protein.

During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.

B. Provide ibuprofen for retroperitoneal discomfort.

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.

C. Monitor intake and output hourly.

Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.

D. Encourage the client to consume at least 2 L of fluid daily.

In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.

A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach

Correct Answer is B

Explanation

A. Kidney beans

Kidney beans are a good plant-based source of protein. They contain essential amino acids, but plant-based proteins may lack some amino acids found in animal-based sources. While kidney beans contribute to protein intake, they are not considered the best source of protein for wound healing among the given options.

B. Grilled salmon

Grilled salmon is indicated as the best source of protein for wound healing among the options. Salmon is an animal-based source that provides high-quality protein with all essential amino acids. It is also rich in omega-3 fatty acids, which have anti-inflammatory properties and can further support the healing process.

C. Peanut butter

Peanut butter is a source of protein, but it is also high in fats. While it can contribute to protein intake, it may not be as lean a source as grilled salmon. It's important to consider the overall nutritional profile when recommending it for wound healing.

D. Raw spinach

Spinach is a source of protein, but it is considered a plant-based protein. While it can contribute to overall protein intake, plant-based proteins may not provide as much protein per serving as animal-based sources like salmon. It also contains other nutrients, such as iron and vitamins, which are beneficial but not specifically highlighted for wound healing in this context.

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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

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about diets that help with wound healing. Which of the following foods should the nurse indicate contains the best source of protein?

Correct Answer is B

Explanation

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