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 ["C","D"]
Explanation
A. Teach a client about hemodialysis:
Educating clients about hemodialysis may require specialized knowledge that might exceed the standard nursing scope. However, nurses may provide basic information and support related to the procedure.
B. Create a plan of care for a client's discharge:
Although nurses often contribute to discharge planning by providing input, assessing needs, and communicating with the care team, the creation of a complete discharge plan may involve multidisciplinary collaboration, including social workers, case managers, and physicians.
C. Assist in checking a unit of packed RBCs to administer to a client:
Nurses are often responsible for verifying blood components (like packed red blood cells) before administration, ensuring proper patient identification, compatibility, and correct handling of the blood product.
D. Regulate the client's infusion pump after initiating a heparin drip infusion:
Nurses frequently regulate and monitor infusion pumps after starting medication infusions, ensuring the correct rate of administration according to the prescribed dosage.
Correct Answer is C
Explanation
A. Adult day care is a service that provides care and supervision to adults who need assistance during the day, often due to physical or cognitive impairments. However, it may not be specifically geared toward providing wound care services.
B. Long-term care typically involves comprehensive, ongoing assistance with activities of daily living for individuals who have chronic illnesses or disabilities. While wound care may be part of long-term care, it's not the primary focus, and it is often provided in various settings, including home care.
C. Wound care is the most appropriate recommendation for an older adult client requiring dressing changes for a healing pressure ulcer. This service may include home health nursing visits to perform the necessary wound care, monitor healing progress, and provide education to the client and their caregivers.
D. Palliative care is focused on providing relief from the symptoms and stress of a serious illness, and it can be appropriate for clients with chronic conditions. However, in this scenario, the primary need is for wound care rather than palliative care.
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