A patient is at risk for developing pressure injuries due to prolonged immobility. Which intervention should the nurse prioritize?
Perform passive range-of-motion exercises daily.
Encourage fluid intake to maintain hydration.
Reposition the patient every 2 hours.
Apply moisturizing lotion to dry skin.
The Correct Answer is C
A. Perform passive range-of-motion exercises daily: Passive ROM helps maintain joint mobility and circulation, but it does not directly relieve pressure on bony prominences. While beneficial, it is not the most immediate intervention to prevent pressure injuries.
B. Encourage fluid intake to maintain hydration: Adequate hydration supports skin turgor and overall tissue health, reducing susceptibility to breakdown. However, hydration alone cannot relieve sustained pressure, so it is not the highest-priority action.
C. Reposition the patient every 2 hours: Frequent repositioning redistributes pressure over bony areas, preventing ischemia and tissue necrosis. For patients with limited mobility, this is the primary and most effective intervention to reduce the risk of pressure injuries.
D. Apply moisturizing lotion to dry skin: Moisturizing helps prevent skin dryness and minor abrasions, supporting skin integrity. It does not alleviate pressure on vulnerable areas and is therefore a secondary preventive measure rather than the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A patient replaces prescribed heart medication with herbal supplements: Alternative medicine involves using nonconventional therapies in place of standard medical treatments. Replacing prescribed medication with herbal remedies exemplifies this approach and carries potential risks if the conventional treatment is necessary for disease management.
B. A patient receives chemotherapy and uses yoga to manage stress: Using complementary therapies alongside standard medical treatment is considered complementary, not alternative medicine. Yoga in this scenario supports symptom management but does not replace conventional therapy.
C. A patient incorporates a balanced diet to support their diabetes management: Dietary management is part of conventional, evidence-based care for diabetes. While healthy, it does not represent alternative medicine because it complements standard treatment protocols.
D. A patient uses meditation alongside medication for hypertension: Meditation is a complementary approach when used with prescribed medications. It does not replace standard care, so it falls under complementary, not alternative, medicine.
Correct Answer is D
Explanation
A. Distributing pamphlets about local health services without collaboration: Providing information alone is a passive approach and may not reach or engage the community effectively. Without collaboration, the intervention may lack cultural relevance and sustainability.
B. Providing individual health assessments for every community member: While comprehensive, this approach is resource-intensive and may be impractical in a rural setting with limited staff and access. It does not leverage community resources for broader impact.
C. Directing all community members to the nearest urban health center: Referring the population to urban centers may create barriers related to transportation, cost, and accessibility. It does not provide locally accessible care or education.
D. Partnering with local schools to implement health education programs: Collaboration with schools provides an accessible, sustainable platform to reach a broad segment of the community. School-based interventions promote health literacy, preventive behaviors, and community engagement, making it the most effective collaborative approach.
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