The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?
Reposition the client at least every two hours.
Encourage the client to limit fluid intake.
Use a donut-shaped cushion under the client's hips.
Apply a heating pad to the client's back every four hours
The Correct Answer is A
A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.
B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.
C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.
D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pulmonary Function Test (PFT). PFTs assess lung function but do not provide diagnostic information for infections like pneumonia.
B. Electrocardiogram (ECG). An ECG assesses heart function and would not help in diagnosing a respiratory infection like pneumonia.
C. Complete Blood Count (CBC). A CBC may indicate infection through elevated white blood cells, but it does not confirm pneumonia or identify its location in the lungs.
D. Chest X-ray. A chest X-ray is the most useful diagnostic tool to confirm pneumonia. It can reveal infiltrates or consolidation in the lungs, which are characteristic of pneumonia.
Correct Answer is D
Explanation
A. Warfarin. Warfarin (Coumadin) is an anticoagulant used to prevent blood clots, but it typically requires several days to achieve a therapeutic effect and needs close monitoring of INR (International Normalized Ratio) levels. While it can be used for long-term prevention of DVT, it's not the immediate choice for post-operative prophylaxis.
B. Alteplase (tPA). Alteplase is a thrombolytic agent, used to break down existing clots, not prevent their formation. It is typically used in emergency situations, such as for treating ischemic stroke.
C. Clopidogrel. Clopidogrel is an antiplatelet agent, often used to prevent arterial clots, not DVTs. It is more commonly used in conditions like stroke and heart disease.
D. Enoxaparin. Enoxaparin, a low molecular weight heparin, is commonly used to prevent DVT after surgery by inhibiting specific clotting factors. It’s frequently prescribed for DVT prevention in orthopedic surgery patients.
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