Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)
Turn immobile clients every 2 hours off bony prominences.
Use lift or draw sheets to move clients in bed.
Keep the moist
Ensure that your client maintains a healthy nutritional status.
Apply pressure-relieving devices to vulnerable areas.
Correct Answer : A,B,D,E
Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.
Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.
Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.
Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.
Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A shortened warning time between the desire to void and actual micturition is a common sign of urinary incontinence in older adults. It is caused by the decreased bladder capacity, increased bladder irritability, and reduced urethral resistance that occur with aging.
Choice B reason: The first urge to void occurs at the midbladder volume (250-350 mL) is not a correct answer, as this is the normal bladder sensation for adults of all ages. It does not indicate urinary incontinence.
Choice C reason: Diarrhea is the most common gastrointestinal complaint made to the health care provider is not a correct answer, as it is not related to urinary incontinence. It is a separate condition that affects the bowel movements.
Choice D reason: Constipation as a symptom of altered bladder functions is not a correct answer, as it is not a direct cause or effect of urinary incontinence. However, constipation can worsen urinary incontinence by increasing the pressure on the bladder and pelvic floor muscles.
Choice E reason: None of the above is not a correct answer, as there is one choice that is true for urinary incontinence in older adults.
Correct Answer is B
Explanation
Choice A: The use of restraints on older patients helps prevent injuries from falls - This statement is not true. The use of restraints can increase the risk of injury and is generally discouraged¹.
Choice B: About 50% to 70% of falls in hospitals occur while transferring between bed and chair - This statement is true. Transfers are a high-risk activity for falls, and appropriate precautions should be taken¹.
Choice C: Falls that do not cause physical injury are not significant - This statement is not true. Even falls without injury can have significant psychological impacts, leading to fear of falling and reduced mobility¹.
Choice D: The get-up-and-go test provides a measure of a patient's energy and initiative - This statement is not true. The get-up-and-go test is used to assess a person's mobility and balance, not their energy and initiative¹.
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