Select two interventions to prevent skin breakdown in a patient with SCI.
Reposition patient q 4hrs or when patient feels discomfort.
Use pressure-reducing mattresses and wheelchair cushions.
Assist the patient to shift position when sitting up in a wheelchair every 2 hours.
Use pillows to protect bony prominences when in bed.
Correct Answer : B,D
Choice A reason: Repositioning every 4 hours is too infrequent for SCI patients; every 2 hours is standard to prevent pressure ulcers. Pressure-reducing mattresses are effective, making this incorrect, as it’s inadequate compared to the nurse’s priority interventions for skin integrity.
Choice B reason: Pressure-reducing mattresses and wheelchair cushions distribute weight, preventing skin breakdown in SCI patients. This aligns with pressure ulcer prevention, making it a correct intervention the nurse would implement to maintain skin integrity in high-risk areas.
Choice C reason: Shifting position every 2 hours in a wheelchair is ideal but applies to patient action, not nurse intervention. Pillows are nurse-driven, making this incorrect, as it’s less nurse-specific than the nurse’s focus on direct interventions like cushions or pillows.
Choice D reason: Using pillows to protect bony prominences reduces pressure on vulnerable areas in SCI patients, preventing skin breakdown. This aligns with skin care protocols, making it a correct intervention the nurse would use to safeguard skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Measuring the ankle-brachial index assesses perfusion but delays addressing an absent pedal pulse, suggesting graft occlusion. Contacting the provider is urgent, making this incorrect, as it’s not the nurse’s first action for a critical post-surgical finding.
Choice B reason: Rechecking the pulse in 30 minutes delays intervention for an absent pulse, risking limb ischemia. Notifying the provider is priority, making this incorrect, as it postpones the nurse’s action to address a potential surgical complication immediately.
Choice C reason: Administering an anticoagulant requires an order and doesn’t address an absent pulse, indicating possible graft failure. Contacting the provider is critical, making this incorrect, as it’s inappropriate compared to the nurse’s need for urgent medical evaluation.
Choice D reason: Contacting the provider is the priority for an absent pedal pulse post-bypass surgery, as it suggests graft occlusion, a surgical emergency. This aligns with post-operative protocols, making it the correct action for the nurse to take immediately.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Excessive oral fluid intake from thirst doesn’t cause ascites, which results from liver dysfunction. Portal hypertension is a cause, making this incorrect, as it misattributes ascites to fluid intake rather than the nurse’s understanding of cirrhosis-related fluid shifts.
Choice B reason: Portal hypertension in cirrhosis increases pressure, pushing proteins into the peritoneal cavity, causing ascites. This aligns with liver pathophysiology, making it a correct cause the nurse would identify for ascites in a patient with liver cirrhosis.
Choice C reason: Decreased albumin synthesis in cirrhosis reduces colloid oncotic pressure, leading to fluid leakage into the peritoneal cavity, causing ascites. This aligns with liver dysfunction, making it a correct cause the nurse would recognize in cirrhosis-related ascites.
Choice D reason: Poor nutrition may cause weight loss, not ascites, which is fluid accumulation from liver issues. Low albumin is a cause, making this incorrect, as it misidentifies the nurse’s expected mechanisms for ascites in liver cirrhosis patients.
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