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 B
Explanation
A. Peripheral edema is typically associated with fluid overload, not hypovolemia. In hypovolemia, the body tries to conserve water, often leading to a decrease in fluid accumulation in the tissues.
B. Oliguria, or reduced urine output, is a common sign of hypovolemia. When there is insufficient fluid volume in the body, the kidneys conserve as much fluid as possible, leading to decreased urine production.
C. Hypovolemia usually leads to hypotension (low blood pressure) as a result of decreased blood volume. It is not typically associated with hypertension.
D. Bradycardia (slow heart rate) is not a direct result of hypovolemia. In fact, hypovolemia more commonly causes tachycardia (increased heart rate) as the body compensates for low blood volume.
Correct Answer is B
Explanation
A. Assisting the client to a low Fowler's position (15 to 30 degrees) is not appropriate for enteral feedings. The client should be positioned at a higher angle (30 to 45 degrees) to reduce the risk of aspiration and improve digestion during feeding.
B. Testing the pH of gastric aspirate is essential to confirm that the NG tube is in the correct position (i.e., the stomach). A pH of 1 to 4 indicates gastric placement, while higher pH values suggest the tube may be in the lungs or intestines. This is a crucial step to ensure safety before administering the feeding.
C. Discarding residual gastric contents is not the correct action. Residual gastric contents should be measured to assess gastric motility and tolerance to the feeding. The feeding should only be withheld if the residual volume is excessive, based on institutional guidelines.
D. Warming the feeding solution to body temperature is not always necessary, although it is often recommended to improve comfort and prevent cramping. The most important step is confirming tube placement and ensuring the feeding is safe.
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