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A nurse plans care for a client who is immobile.
Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Place a small pillow between bony surfaces.

Elevate the head of the bed to 45 degrees.

Limit fluids and proteins in the diet.

Use a lift sheet to assist with re-positioning.

Re-position the client who is in a chair every 2 hours.

Keep the client's heels off the bed surfaces.

Use a rubber ring to decrease sacral pressure when up in the chair.

Answer and Explanation

Correct Answer : A,D,F

Choice A rationale

Placing a small pillow between bony surfaces effectively redistributes pressure, preventing the sustained compression that leads to tissue ischemia. This action minimizes direct bone-on-bone contact and provides cushioning, which enhances blood flow to the skin and subcutaneous tissues. The goal is to avoid prolonged pressure on any single area, thereby mitigating the risk of capillary occlusion and subsequent pressure sore formation.

Choice B rationale

Elevating the head of the bed to 45 degrees increases the risk of shearing forces. Shearing occurs when the skin remains stationary while the underlying tissue shifts and moves, stretching and tearing small blood vessels. This disrupts circulation, making the tissue more susceptible to ischemia and breakdown. A lower angle, typically 30 degrees or less, is recommended to minimize this damaging effect and reduce the risk of pressure sore development.

Choice C rationale

Limiting fluids and proteins in the diet is counterproductive. Adequate hydration is essential for maintaining skin turgor and tissue perfusion. Protein is a critical component for tissue repair and cell regeneration. A deficiency in these nutrients impairs the body’s ability to heal existing wounds and makes the skin more fragile and susceptible to injury, significantly increasing the risk of pressure sore formation.

Choice D rationale

Using a lift sheet is a fundamental intervention for safe repositioning. It prevents the friction and shear that occur when a client is dragged across a surface. Friction is the mechanical force of two surfaces rubbing against each other, which can strip away the outer layers of the epidermis. A lift sheet protects the skin by ensuring smooth, controlled movements, thus preserving skin integrity and reducing the risk of pressure sores.

Choice E rationale

Repositioning a client in a chair every 2 hours is insufficient. The pressure exerted on the buttocks and sacrum when seated is typically greater than when lying in bed. Therefore, clients in a chair should be repositioned or encouraged to shift their weight more frequently, usually every hour, to relieve pressure points. This more frequent movement prevents sustained compression and promotes adequate blood flow to the at-risk areas.

Choice F rationale

Keeping the client's heels off the bed surfaces is crucial because heels are highly susceptible to pressure sore formation. They are bony prominences with limited subcutaneous fat, making them particularly vulnerable to sustained pressure. Placing a pillow under the calves to float the heels completely off the bed effectively eliminates this pressure, ensuring continuous blood flow to the heel tissue and preventing ischemic damage.

Choice G rationale

Using a rubber ring to decrease sacral pressure is a harmful practice. A rubber ring, or donut cushion, actually increases pressure on the surrounding tissues, leading to a "donut-shaped" area of ischemia. The hole in the middle of the ring focuses pressure around the edges, disrupting blood flow and increasing the risk of tissue breakdown. Specialized cushions that distribute pressure evenly are the recommended alternative.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale

Bathing a child with infantile eczema using products containing fragrance can be irritating to the already compromised skin barrier. Fragrances are common allergens and can trigger or worsen the inflammatory response in atopic dermatitis. It is essential to use fragrance-free, hypoallergenic products to minimize irritation and prevent exacerbations.

Choice B rationale

Using oatmeal and baking soda as bath additives can be soothing for the irritated skin of a child with infantile eczema. Colloidal oatmeal contains avenanthramides which have anti-inflammatory and antioxidant properties, while baking soda can help to relieve itching. These additives can help to calm the skin and reduce the urge to scratch.

Choice C rationale

Adding bath oil to bath water after the child has soaked for a period of time is a beneficial practice. Soaking in water allows the skin to rehydrate. Adding the oil at the end of the bath helps to seal in the moisture, forming a protective barrier and preventing transepidermal water loss, which is a key issue in eczema.

Choice D rationale

Lanolin is a fatty substance derived from sheep wool. While it can be a good moisturizer, it is also a common allergen. Applying lanolin-based lotions to a child with eczema can potentially trigger an allergic reaction or worsen the skin condition. It is safer to use hypoallergenic, non-irritating moisturizers.

Choice E rationale

Bathing a child several times a day can strip the skin of its natural oils, which can worsen the dryness and irritation associated with infantile eczema. The skin barrier is already compromised, and frequent bathing can exacerbate this problem. It is generally recommended to limit bathing to once a day or less to maintain skin integrity. .

A. Requests a referral to a registered dietitian nutritionist. B. Raises the head of the bed no more than 45 degrees. C. Performs perineal cleansing every 2 hours. D. Assesses the client's entire skin surface daily.

Correct Answer is C

Explanation

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.

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A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a teaching plan for the care of a child with infantile eczema. What interventions would the nurse include? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?

Correct Answer is C

Explanation

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A nurse plans care for a client who is immobile.
Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)