Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

pulling the client up from under the arms

improving the client's hydration

lubricating the area with skin cream

preventing the client from sliding in bed

Answer and Explanation

The Correct Answer is D

A) Pulling the client up from under the arms: This action can increase shearing force on the client's skin, especially if done abruptly or without proper assistance. Pulling the client up by the arms can create friction and shear between the skin and underlying tissues, potentially worsening the pressure injury.
B) Improving the client's hydration: While hydration is essential for overall skin health, it is not directly related to reducing shearing force on a pressure injury. Hydration can help maintain skin integrity and promote healing but does not directly address the mechanical forces contributing to pressure injuries.
C) Lubricating the area with skin cream: While skin cream can help moisturize and protect the skin, it may not necessarily reduce shearing force on a pressure injury. While lubrication can reduce friction between surfaces, it may not be sufficient to prevent shearing forces that occur during movement or repositioning.
D) Preventing the client from sliding in bed: This is the most appropriate action to decrease shearing force on a stage II pressure injury. Sliding in bed can exacerbate shearing forces on the skin, leading to further damage or delayed healing of the pressure injury. Using devices such as pillows, positioning aids, or specialized mattresses can help prevent the client from sliding and minimize shearing forces on the affected area, promoting healing and preventing further injury.

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Correct Answer is C

Explanation

A) Lactated Ringer's:
Lactated Ringer's solution is an isotonic crystalloid solution that contains electrolytes similar to those found in plasma. It is commonly used for fluid resuscitation and maintenance therapy but is not typically used for treating hypernatremia, as it contains sodium chloride and could exacerbate the client's condition.

B) Dextrose 10% in water:
Dextrose 10% in water is a hypertonic solution primarily used to provide calories and treat hypoglycemia. It does not address the underlying electrolyte imbalance in hypernatremia.

C) 0.45% sodium chloride:
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution used to treat hypernatremia by diluting the excess sodium in the bloodstream. It provides free water to rehydrate cells without adding excessive sodium. This solution is appropriate for clients with hypernatremia who require IV fluid therapy.

D) Dextrose 5% in 0.9% sodium chloride:
Dextrose 5% in 0.9% sodium chloride, also known as D5NS, is a hypertonic solution containing both dextrose and sodium chloride. While it provides water and calories, the sodium content may exacerbate hypernatremia rather than correct it. Therefore, it is not the most appropriate choice for a client with hypernatremia.

A. Increase hematocrit B. Increased temperature C. Increased heart rate D. Increased respiratory rate E. Increased blood pressure

Correct Answer is ["C","D","E"]

Explanation

A) Increase hematocrit: Fluid overload typically results in dilutional effects on the blood, leading to a decrease in hematocrit rather than an increase. Hematocrit levels may decrease due to the relative decrease in the concentration of red blood cells in relation to plasma.

B) Increased temperature: Fluid overload is not typically associated with an increase in body temperature. While fever can occur as a result of infection, it is not a direct manifestation of fluid overload.

C) Increased heart rate: Fluid overload can lead to increased blood volume, which results in an increased workload for the heart. As a compensatory mechanism, the heart rate may increase to maintain adequate cardiac output.

D) Increased respiratory rate: Fluid overload can cause pulmonary congestion and impair gas exchange in the lungs, leading to respiratory distress. As a result, the respiratory rate may increase as the body attempts to compensate for the decreased oxygenation.

E) Increased blood pressure: Fluid overload can lead to an increase in blood volume, which results in increased pressure within the blood vessels. As a result, blood pressure may rise as the heart works harder to pump the excess fluid throughout the body.

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Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Correct Answer is C

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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