What nursing interventions decrease the risk of pressure injuries? (Select all that apply.)
Padding hard surfaces
Keep head of bed (HOB) at or less than 30 degrees
Keep head of bed (HOB) elevated to 75 degrees
Have client sit in wheelchair as much as possible
Place pillows between bony surfaces.
Correct Answer : A,B,E
Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.
Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.
Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.
Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.
Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.
Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.
Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.
Correct Answer is A
Explanation
Choice A reason: Primary intention is the correct answer, because it is the type of wound healing that occurs when the wound edges are approximated and closed with sutures, staples, or glue. Primary intention is the fastest and most effective way of wound healing, as it minimizes tissue loss, infection, and scarring.
Choice B reason: Secondary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are not approximated and left open to heal by granulation, contraction, and epithelialization. Secondary intention is the slowest and least effective way of wound healing, as it results in more tissue loss, infection, and scarring.
Choice C reason: Tertiary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are initially left open and then closed with sutures, staples, or glue after a period of time. Tertiary intention is a delayed form of primary intention, and it is used when the wound is contaminated, infected, or requires drainage.
Choice D reason: Binary intention is not the correct answer, because it is not a real term for wound healing. Binary intention is a madeup term that does not describe any specific process or outcome of wound healing.
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