An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?
Apply lotion to sacrum.
Use wet-to-dry dressings daily.
Elevate head of bed 30 degrees.
Change positions every 2 hours.
The Correct Answer is D
A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Provide a PRN hypnotic medication: Administering a hypnotic should not be the first response without first assessing the underlying cause of the sleep difficulty. Non-pharmacological approaches are safer, especially for older adults who are more sensitive to sedative side effects.
B. Reassure the client that it is still early: Simply reassuring the client does not address the immediate concern of why the client cannot sleep. Dismissing the complaint without assessment may lead to prolonged distress and unresolved sleep disturbances.
C. Evaluate the room environment: Assessing the room for factors like noise, lighting, temperature, and comfort is a priority because environmental factors often contribute significantly to insomnia. Addressing modifiable conditions can promote natural sleep without immediately resorting to medications.
D. Close the door to the client's room: While closing the door might reduce noise, it is a single action that may not fully address all potential environmental issues affecting sleep. A complete evaluation of the environment is necessary first to identify and correct all possible disruptions.
Correct Answer is B
Explanation
A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.
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