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A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

A.

Every four hours.

B.

Every hour.

C.

Every shift.

D.

Every two hours

Answer and Explanation

The Correct Answer is D

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.


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Related Questions

Correct Answer is A

Explanation

A. To prevent contractions in the hand:

The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.

B. To prevent skin breakdown:

While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.

C. To prevent decreased perfusion in the lower extremities:

The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.

D. To prevent pooling of blood in the hand:

While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.

Correct Answer is A

Explanation

A. 74-year-old female with malnutrition and a foley catheter in place:

Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.

B. 54-year-old female admitted for chest pain observation:

Chest pain observation does not inherently increase the risk of infection.

C. 34-year-old male admitted for seizure observation:

Seizure observation does not inherently increase the risk of infection.

D. 78-year-old male with right-sided hemiplegia following a stroke:

While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.

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