A nurse is providing discharge teaching to a caregiver about preventing pressure ulcers in a bedridden patient. Which statement by the caregiver indicates a need for further teaching?

“I will reposition every 2 hours to prevent pressure injuries."

“I should apply warm compresses to any red areas to improve circulation and prevent ulcers."

“I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing."

“I should use foam cushions and heel protectors to relieve pressure on bony prominences."

Answer and Explanation

The Correct Answer is B

A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

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Correct Answer is B

Explanation

A. “I can bend my hip beyond 90 degrees as long as I feel comfortable." Flexing the hip beyond 90 degrees increases the risk of hip dislocation.

B. “I should avoid turning onto my operative side to prevent hip dislocation." Lying on the operative side increases pressure on the hip joint and can lead to dislocation or delayed healing.

C. “I don't need to use a pillow or abduction device between my legs when turning." An abduction pillow or device is necessary to keep the legs apart and prevent hip adduction, which can lead to dislocation.

D. “I should cross my legs when sitting to keep my hip stable." Crossing the legs can cause internal rotation and hip dislocation.

A. Obtain a prescription to adjust the weight amount. B. Administer an opioid analgesic C. Realign the client's position. D. Offer a muscle relaxant to the client.

Correct Answer is C

Explanation

A. Obtain a prescription to adjust the weight amount: Adjusting the weight could help relieve muscle spasms, but the nurse should first try non-invasive interventions such as repositioning before requesting a prescription change.

B. Administer an opioid analgesic: Pain medication can help manage discomfort, but it does not address the cause of the muscle spasms. Non-pharmacologic interventions should be attempted first.

C. Realign the client’s position: This is the first action the nurse should take. Incorrect positioning can contribute to muscle spasms, and realignment can often provide immediate relief. This intervention is non-invasive and should be attempted before medication or weight adjustments.

D. Offer a muscle relaxant to the client: Muscle relaxants can be helpful, but they should be considered only after non-pharmacologic measures like repositioning fail.

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A nurse is providing discharge teaching to a caregiver about preventing pressure ulcers in a bedridden patient. Which statement by the caregiver indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements by the patient is correct regarding postoperative positioning after total hip arthroplasty?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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