When providing care for a client who has facial fractures, the nurse notices a strong mouth odor. Which of the following terms should the nurse use to document this finding?

A. Massage the client’s bony prominences:

Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.

B. Keep the head of the bed elevated:

While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.

C. Reposition the client at least every 2 hr:

Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.

D. Keep the client’s skin moist:

While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.

A. “I will call for pain medication before the previous dose wears off.”

The statement "I will call for pain medication before the previous dose wears off" indicates an understanding of proactive pain management. In postoperative pain control, it is generally more effective to stay ahead of the pain by taking pain medication on a scheduled basis rather than waiting until the pain becomes severe. This approach helps to maintain a more consistent level of pain relief.

B. “I will call for pain medication as my pain becomes intolerable.”

Waiting until the pain becomes intolerable may result in suboptimal pain control. It's more effective to take pain medication before reaching a point of intolerable pain.

C. “I will wait for you to evaluate my pain before asking for more.”

Waiting for the nurse to evaluate pain before requesting more medication may result in delays in pain relief. Pain management often involves collaboration between healthcare providers and patients, and timely communication about pain levels is essential.

D. “I will ask for less medication to avoid addiction.”

This statement reflects a concern about addiction but may lead to inadequate pain relief. Pain management should prioritize effective pain control while balancing the risks and benefits of medications. The goal is to provide sufficient pain relief without compromising the client's well-being.