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 A
Explanation
A. Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, which involves damage to the epidermis and possibly the dermis. The red tissue is typically granulation tissue or viable tissue.
B. Intact skin with localized erythema would be indicative of a stage 1 pressure injury, where the skin remains intact but shows redness or non-blanching erythema.
C. Full-thickness skin loss with visible adipose tissue would describe a stage 3 pressure injury, which involves damage to the full dermis and subcutaneous tissue, exposing fat.
D. Full-thickness skin loss with visible bone would describe a stage 4 pressure injury, which extends through all layers of the skin and tissue to expose bone, tendon, or muscle.
Correct Answer is A
Explanation
A. Identifying clients at greatest risk for pressure ulcers is the priority because it allows healthcare providers to focus preventive efforts on those who are most vulnerable. Risk assessments help guide interventions such as repositioning, nutrition, and skin care.
B. While using a barrier cream is important to protect the skin from moisture and friction, it is not as critical as first identifying those at high risk for pressure ulcers so that appropriate preventive measures can be tailored to their needs.
C. Turning and positioning clients every 2 hours is a standard preventive measure, but it is more effective when applied to those at highest risk. Identifying those individuals first is essential for ensuring the proper allocation of care resources.
D. Ensuring adequate nutritional intake is important in the prevention of pressure ulcers, but again, identifying at-risk clients is the first step to properly directing all interventions, including nutritional support.
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