A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
Elevate the head of the client's bed 45°
Massage the client's bony prominences
Provide the client with a high-calorie diet
Reposition the client every 4 hrs
The Correct Answer is C
A. Elevating the head of the bed to 45° may increase the risk for pressure injuries, especially on the sacrum, due to increased pressure and friction from sliding down. The head of the bed should be kept as low as possible, typically at 30°, to reduce this risk.
B. Massaging bony prominences is not recommended for clients at risk for pressure injuries. Massage can cause tissue damage and exacerbate pressure injury formation. It is better to avoid massaging areas prone to injury and instead use appropriate repositioning techniques.
C. Providing a high-calorie diet is essential for clients at risk for pressure injuries. Adequate nutrition, including high-protein and high-calorie foods, helps support skin integrity, wound healing, and overall tissue repair, reducing the risk of developing pressure injuries.
D. Repositioning the client every 4 hours is insufficient for preventing pressure injuries. Clients at risk should be repositioned at least every 2 hours to relieve pressure on vulnerable areas and promote circulation to the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Elevating the head of the bed to 45° may increase the risk for pressure injuries, especially on the sacrum, due to increased pressure and friction from sliding down. The head of the bed should be kept as low as possible, typically at 30°, to reduce this risk.
B. Massaging bony prominences is not recommended for clients at risk for pressure injuries. Massage can cause tissue damage and exacerbate pressure injury formation. It is better to avoid massaging areas prone to injury and instead use appropriate repositioning techniques.
C. Providing a high-calorie diet is essential for clients at risk for pressure injuries. Adequate nutrition, including high-protein and high-calorie foods, helps support skin integrity, wound healing, and overall tissue repair, reducing the risk of developing pressure injuries.
D. Repositioning the client every 4 hours is insufficient for preventing pressure injuries. Clients at risk should be repositioned at least every 2 hours to relieve pressure on vulnerable areas and promote circulation to the skin.
Correct Answer is B
Explanation
A. "My breath may have a fruity odor." — Fruity breath odor is typically associated with diabetic ketoacidosis (DKA), a serious complication of diabetes, which is usually seen in cases of severe hyperglycemia or insulin deficiency. However, hyperglycemia alone without DKA does not generally cause fruity breath.
B. "I will be more thirsty than usual." — Increased thirst (polydipsia) is a common symptom of hyperglycemia. High blood sugar leads to increased urination, which can cause dehydration, triggering thirst as a compensatory mechanism.
C. "My appetite will be decreased." — Decreased appetite is not a typical manifestation of hyperglycemia. In fact, some people with hyperglycemia may experience an increased appetite, especially if they are not effectively managing their blood glucose levels.
D. "I might experience blurry vision at times." — While blurry vision can occur with hyperglycemia due to fluid changes in the eyes, it is more of a chronic symptom associated with poorly controlled diabetes rather than an immediate manifestation. It typically results from prolonged high blood sugar, not just temporary hyperglycemia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.