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 A
Explanation
A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.
Correct Answer is A
Explanation
A. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown: Frequent repositioning is critical to prevent pressure injuries in bedfast clients. Although the redness blanched (indicating no permanent damage yet), regular turning is necessary to maintain skin integrity and prevent future breakdown.
B. Confirm that turning this client once a shift is sufficient since no skin damage occurred: Turning once per shift is inadequate for pressure injury prevention. Clients at risk need to be repositioned at least every two hours to minimize sustained pressure on bony prominences.
C. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris: Since there is no open wound, aggressive cleansing is unnecessary and could actually irritate the skin further. The focus should be on pressure relief rather than harsh skin cleansing.
D. Gather supplies to apply a sterile dressing over the site to reduce risk for infection: A sterile dressing is not appropriate for blanchable redness without skin breakdown. Preventive measures like repositioning and pressure relief are the correct interventions at this stage.
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