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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Fecal impaction is not the most common gastrointestinal complaint, as it is a condition that occurs when hardened stool accumulates in the rectum and cannot be expelled. Fecal impaction may cause abdominal pain, bloating, nausea, and loss of appetite. Fecal impaction is more common in older adults, people with low-fiber diets, or people who take certain medications, such as opioids or anticholinergics.

Choice B reason: Diarrhea is the most common gastrointestinal complaint, as it is a condition that occurs when the stool is loose, watery, and frequent. Diarrhea may cause dehydration, electrolyte imbalance, and malabsorption. Diarrhea can be caused by various factors, such as infections, food intolerance, medications, or irritable bowel syndrome.

Choice C reason: Constipation is not the most common gastrointestinal complaint, as it is a condition that occurs when the stool is hard, dry, and infrequent. Constipation may cause straining, pain, bleeding, and hemorrhoids. Constipation can be caused by various factors, such as lack of fluids, fiber, or exercise, or certain medications, such as antacids or iron supplements.

Choice D reason: Hemorrhoids are not the most common gastrointestinal complaint, as they are swollen veins in the lower rectum or anus that may cause itching, pain, or bleeding. Hemorrhoids can be caused by various factors, such as constipation, straining, pregnancy, or aging.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most common gastrointestinal complaint.

A. 2400 mL/day B. 1920 mL/day C. 3000 mL/day D. 1500 mL/day

Correct Answer is A

Explanation

Choice A reason: 2400 mL/day is the recommended fluid intake for older adults, according to the National Council on Aging. This amount can help prevent dehydration, which can cause various health problems in older adults, such as urinary tract infections, constipation, confusion, and falls.

Choice B reason: 1920 mL/day is not enough fluid intake for older adults, as it is below the minimum requirement of 6-8 glasses of fluid a day, according to Age UK. This amount can increase the risk of dehydration and its complications in older adults.

Choice C reason: 3000 mL/day is too much fluid intake for older adults, as it exceeds the maximum limit of 10 glasses of fluid a day, according to The Conversation. This amount can cause overhydration, which can lead to hyponatremia, a condition where the sodium level in the blood becomes too low. Hyponatremia can cause symptoms such as nausea, headache, confusion, and seizures.

Choice D reason: 1500 mL/day is not enough fluid intake for older adults, as it is half of the recommended amount of 2400 mL/day, according to the National Council on Aging. This amount can increase the risk of dehydration and its complications in older adults.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most common gastrointestinal complaint made to a health care provider?

Correct Answer is B

Explanation

Older adults should consume how much fluid per day?

Correct Answer is A

Explanation

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