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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Contusion refers to a bruise caused by blunt force trauma, leading to tissue damage without a break in the skin. It is not consistent with torn skin tissue.
B. Abrasion is a superficial wound that affects only the outer layers of the skin, typically caused by friction. It would not involve torn skin tissue beneath the surface.
C. Laceration refers to a wound that involves a tear or cut in the skin, often with irregular edges. This is the most accurate description when there is torn skin tissue underneath.
D. Puncture involves a wound that is caused by a sharp object piercing the skin, typically leaving a small, deep hole. It is not associated with torn skin tissue.

A. Choose orange juice instead of apple juice. B. Replace sugar with molasses when baking. C. Eat granola for breakfast. D. Avoid using salt substitutes when cooking.

Correct Answer is D

Explanation

A. Orange juice is high in potassium, and therefore it should be avoided on a low potassium diet. Apple juice typically has a lower potassium content, so it is a better choice.
B. Molasses is high in potassium and should be avoided on a low potassium diet. Replacing sugar with molasses would increase the potassium intake, which could be harmful for someone on a low potassium diet.
C. Granola can be high in potassium if it contains nuts, dried fruits, or other potassium-rich ingredients. It may not be suitable for a low potassium diet.
D. Salt substitutes often contain potassium chloride as a replacement for sodium chloride. This can increase potassium levels, so the nurse should instruct the client to avoid using salt substitutes to maintain proper potassium balance.

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A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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