A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?
Use an air-assisted device.
Position the bed in reverse Trendelenburg.
Elevate the head of bed to a 45° angle.
Lower the bed close to the ground.
The Correct Answer is A
A. Use an air-assisted device.
Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.
B. Position the bed in reverse Trendelenburg:
Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.
C. Elevate the head of bed to a 45° angle:
While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.
D. Lower the bed close to the ground:
Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incentive spirometer:
An incentive spirometer is used to encourage deep breathing and prevent respiratory complications, but it is not specifically indicated for the management of sleep apnea.
B. Continuous positive airway pressure (CPAP) machine.
The description of the client stopping breathing for 30-second intervals while sleeping at night is suggestive of sleep apnea. A Continuous Positive Airway Pressure (CPAP) machine is commonly used for the management of sleep apnea. It delivers a continuous stream of air to keep the airway open, preventing pauses in breathing during sleep.
C. Yankauer suction equipment:
Yankauer suction equipment is used for oral suctioning and is not related to addressing the breathing pauses associated with sleep apnea.
D. Nebulizer:
A nebulizer is used to administer inhaled medications, typically for respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD). It is not the primary equipment for addressing the respiratory pauses seen in sleep apnea.
Correct Answer is ["1.5"]
Explanation
To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
- Volume = 500 mg/ 330 mg/mL
- Volume≈1.5mL
Therefore, the nurse should administer approximately 1.5 mL per dose of cefazolin 500 mg IM.
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