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 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.

A. "Allopurinol helps to lower uric acid levels and prevent future gout attacks." B. “I should take allopurinol during an acute gout attack to relieve pain immediately." C. “I should avoid drinking water while taking allopurinol to prevent kidney stones." D. "Allopurinol works by reducing inflammation in my joints during a flare-up."

Correct Answer is A

Explanation

A. "Allopurinol helps to lower uric acid levels and prevent future gout attacks." Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production, helping to prevent future gout attacks rather than treating acute flares.

B. “I should take allopurinol during an acute gout attack to relieve pain immediately." Allopurinol is not used for acute gout attacks because it does not have immediate pain-relieving or anti-inflammatory effects. In fact, starting or increasing allopurinol during an acute attack may worsen symptoms.

C. “I should avoid drinking water while taking allopurinol to prevent kidney stones." Adequate hydration is essential while taking allopurinol to prevent uric acid kidney stones and to help eliminate excess uric acid from the body.

D. "Allopurinol works by reducing inflammation in my joints during a flare-up." Allopurinol does not have anti-inflammatory properties. It lowers uric acid levels over time, reducing the risk of future gout attacks but not treating acute inflammation.

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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?

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Naxlex Comprehensive Predictor Exams

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