The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?
Sacrum.
Ischial tuberosities.
Lateral malleolus
Iliac crest.
The Correct Answer is D
A. Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.
B. Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.
C. Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.
D. Iliac crest: The iliac crest on the side the client is turned onto bears significant pressure in the lateral position. It is a major bony prominence directly exposed to force against the mattress, making it the most likely site to show early erythema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increase the daily oral fluid intake: Increasing fluid intake is one of the best non-pharmacological strategies to prevent constipation, especially in older adults. Adequate hydration helps soften stool, promotes regular bowel movements, and supports overall digestive health during travel and routine changes.
B. Decrease the fat content in your diet: Reducing dietary fat is more related to managing cardiovascular health rather than preventing constipation. Fats themselves do not contribute significantly to constipation, and this advice would not directly address the client's specific concern.
C. Use an over-the-counter (OTC) stool softener: While stool softeners can be useful, recommending their routine use without first trying dietary and lifestyle modifications is not the best initial approach. Relying on medications can sometimes lead to dependency or mask underlying issues.
D. Eat a high-protein diet: High-protein diets without sufficient fiber and fluids can actually worsen constipation. Protein is important for overall health, but preventing constipation primarily requires fiber intake and adequate hydration rather than increased protein alone.
Correct Answer is B
Explanation
A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.
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