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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I’ll apply ice to my ankle for 20 minutes every hour."

This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.

B. "I’ll rewrap my ankle starting from the knee down."

This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.

C. "I’ll walk on my ankle for 10 minutes every hour."

This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.

D. "I’ll put a heating pad on my ankle at bedtime tonight."

This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.

A. The stockings are used to reduce pain. B. The stockings prevent varicose veins. C. The stockings prevent venous stasis. D. The stockings replace the need for postoperative leg exercises.

Correct Answer is C

Explanation

A. The stockings are used to reduce pain.

This statement is not accurate. While antiembolism stockings may provide some relief from discomfort and swelling, their primary purpose is to prevent venous stasis and reduce the risk of blood clots, not to directly reduce pain.

B. The stockings prevent varicose veins.

This statement is not entirely accurate. While compression stockings can provide some support to veins, their primary role is in preventing blood clots (venous thromboembolism) rather than preventing varicose veins, which are typically related to venous insufficiency.

C. The stockings prevent venous stasis.

This is the correct answer. Antiembolism stockings are specifically designed to prevent venous stasis, which refers to the slowing or stagnation of blood flow in the veins. They exert gentle pressure on the legs to enhance blood circulation and reduce the risk of blood clots.

D. The stockings replace the need for postoperative leg exercises.

This statement is not accurate. While antiembolism stockings are a preventive measure, they do not replace the need for postoperative leg exercises. Leg exercises are important for promoting circulation, preventing complications such as deep vein thrombosis (DVT), and maintaining overall mobility after surgery.

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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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