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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Asthma: Asthma is a respiratory condition and is not a common complication associated with diabetes.

B. Osteoporosis: Osteoporosis is a bone disease more commonly associated with hormonal changes, aging, or steroid use, not directly linked to diabetes.

C. Liver cirrhosis: Liver cirrhosis is usually caused by alcohol use, hepatitis, or other liver diseases, not directly due to diabetes.

D. Cardiovascular disease: Diabetes is a significant risk factor for cardiovascular disease due to its association with atherosclerosis, hypertension, and dyslipidemia.

A. Initiation of a high-sodium diet B. Application of a cast to the affected limb C. Administration of anticoagulant therapy D. Administration of bronchodilators

Correct Answer is C

Explanation

A. Initiation of a high-sodium diet. A high-sodium diet is not indicated in pulmonary embolism management; it could worsen fluid retention and cardiovascular strain.

B. Application of a cast to the affected limb. Casting is not appropriate for pulmonary embolism, as it is not an orthopedic injury. Immobilization could increase the risk of further clot formation.

C. Administration of anticoagulant therapy. Anticoagulant therapy, such as heparin or warfarin, is the primary treatment for pulmonary embolism to prevent further clot formation and allow the body to dissolve the clot.

D. Administration of bronchodilators. Bronchodilators may alleviate respiratory symptoms but do not treat the underlying clot in pulmonary embolism. Anticoagulation remains the primary treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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