Pressure injuries can occur to the skin and underlying tissues due to pressure, shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)

Inspect the sacrum for blanching

Frequent turning and positioning

Optimizing nutrition

Frequent skin assessments

Maintaining the head of the bed at a 45-degree angle

Answer and Explanation

Correct Answer : B,C,D

A. Inspect the sacrum for blanching: While inspecting for blanching is important for early detection of pressure injuries, it does not directly prevent them. Prevention involves proactive measures like turning and positioning.

B. Frequent turning and positioning: Regular repositioning helps relieve pressure on vulnerable areas and prevents the formation of pressure injuries, especially in immobile patients.

C. Optimizing nutrition: Proper nutrition, including adequate protein and calorie intake, helps maintain skin integrity and supports wound healing, reducing the risk of pressure injuries.

D. Frequent skin assessments: Regular skin checks help identify early signs of pressure injuries such as erythema, warmth, or localized pain allow for early intervention to prevent worsening.

E. Maintaining the head of the bed at a 45-degree angle: Keeping the head of the bed elevated too high can increase pressure on the sacrum and promote shear forces. A lower angle (30 degrees or less) is often recommended to reduce pressure.

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Correct Answer is B

Explanation

A. Administration of a vasopressor: While vasopressors are used in sepsis to increase blood pressure, they are typically administered after fluid resuscitation has been initiated. This patient requires fluids first to restore circulation before considering vasopressors.

B. Initiation of a blood transfusion: There is no indication of acute blood loss or anemia (hemoglobin and hematocrit are stable). Blood transfusions are used for patients with significant blood loss or low hemoglobin, which is not the case here.

C. Initiation of aggressive fluid resuscitation: The patient is showing signs of sepsis, as evidenced by fever, elevated WBC count, low blood pressure, and elevated lactate, which indicates poor tissue perfusion. The Surviving Sepsis Campaign recommends early and aggressive fluid resuscitation with isotonic fluids (like Lactated Ringer’s). The provider has already ordered 1000mL Lactated Ringer's at 170mL/hr to address this.

D. Administration of acetaminophen: Although acetaminophen may help manage fever, it does not address the underlying issue of sepsis or impaired perfusion. The priority is fluid resuscitation to improve circulation and oxygen delivery to tissues.

A. Cimetidine B. Pantoprazole C. Famotidine D. Ranitidine

Correct Answer is B

Explanation

A. Cimetidine: Cimetidine is an H2 receptor antagonist, not a proton pump inhibitor (PPI). While H2 blockers like cimetidine reduce stomach acid, they are not classified as PPIs.

B. Pantoprazole: Pantoprazole is a proton pump inhibitor (PPI) and is commonly used to treat peptic ulcers. PPIs work by inhibiting the proton pump in the stomach, thereby reducing gastric acid production, which helps in healing peptic ulcers.

C. Famotidine: Famotidine is an H2 receptor antagonist, similar to cimetidine, and works by reducing acid secretion in the stomach. While effective for ulcers, it is not a proton pump inhibitor.

D. Ranitidine: Ranitidine is also an H2 receptor antagonist, which works by reducing stomach acid but does not have the same mechanism as a proton pump inhibitor like pantoprazole.

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Pressure injuries can occur to the skin and underlying tissues due to pressure, shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)

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