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 D
Explanation
A. Wear a surgical mask during all client contact: While wearing a surgical mask protects the nurse from inhaling respiratory droplets, it is equally important to prevent the client from spreading droplets to others, especially when moving outside the room.
B. Use an isolation gown when providing client care: An isolation gown protects against contact transmission rather than droplet transmission. Influenza spreads primarily through respiratory droplets, so gowns are not the primary measure to prevent its spread.
C. Determine if the client's room has negative airflow: Negative airflow rooms are necessary for airborne infections like tuberculosis, not for droplet-spread infections such as influenza. Standard precautions for influenza focus more on masking and hygiene practices.
D. Place a mask on the client if the client leaves the room: Masking the client when outside their room helps contain respiratory droplets, minimizing the risk of infecting others. This intervention is crucial in controlling the spread of influenza within healthcare settings.
Correct Answer is ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
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