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. Hold your breath for 7 seconds when using the incentive spirometer is correct. To achieve optimal lung expansion, clients should inhale deeply and hold their breath for 3 to 5 seconds, though some guidelines may recommend up to 7 seconds, which helps to maximize the effectiveness of the inhalation.
B. Sit up at a 30-degree angle when using the incentive spirometer is not accurate. Clients should ideally sit upright or in a semi-Fowler’s position, but a 30-degree angle is not a strict requirement for using the spirometer. The key is to have an optimal posture for deep breathing.
C. Use the incentive spirometer once every 4 hours is incorrect. The incentive spirometer should be used every 1 to 2 hours while awake, not just once every 4 hours, to encourage frequent deep breathing and reduce the risk of atelectasis.
D. Inhale through the incentive spirometer 10 times with each use is not necessarily recommended. The general guidance is to perform 5 to 10 slow, deep breaths per session, but this can vary depending on the patient’s condition and specific instructions from their healthcare provider.
Correct Answer is C
Explanation
A. Providing more stimulation might not address the root cause of the behavior and could escalate the situation if the client becomes more agitated or confused.
B. Waiting to see if the behavior continues is not the most appropriate action, as it may delay necessary interventions. Additionally, it could increase the risk of harm to the client.
C. Calling the doctor to obtain a prescription for a restraint, if necessary, is the correct procedure. Restraints should only be used as a last resort, following proper protocols, and should always be ordered by a physician.
D. Covering the catheter so the client cannot see it might not address the underlying issue and is not an appropriate solution to managing behavior. It may also be a safety concern if it interferes with monitoring or use of the tube.
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