Which activity should the nurse implement to decrease the possibility of skin breakdown and injury while in bed?
Support the client from sliding in bed.
Pull client up under the arms during repositioning.
Improve the client's hydration with carbonated drinks.
Lubricate the skin with petroleum based oils.
The Correct Answer is A
Choice A rationale
Supporting the client from sliding in bed helps prevent shear and friction, which are major contributors to skin breakdown and pressure injuries. Shearing occurs when the skin remains stationary against the sheets while the underlying tissue and bone move downward, damaging the deep capillary beds. By using pillows, wedges, or adjusting the bed position (such as keeping the head of the bed at or below 30 degrees), the nurse reduces the gravitational force that causes the client to slide.
Choice B rationale
Pulling a client up under the arms during repositioning is a dangerous practice that increases the risk of friction and skin tears. This method concentrates a large amount of force on a small area of skin and can also cause musculoskeletal injury to both the client and the nurse. Instead, nurses should use friction-reducing devices like draw sheets or slide boards and utilize a team approach to lift the client off the bed surface, thereby protecting the integrity of the epidermis.
Choice C rationale
While hydration is essential for maintaining skin turgor and health, carbonated drinks are not an ideal source. These beverages often contain high amounts of sugar or caffeine, which can lead to diuresis and potentially worsen dehydration. Furthermore, carbonation can cause gastric distension and discomfort. For optimal skin health, clients should be encouraged to consume water or balanced electrolyte solutions that support cellular hydration without the negative side effects associated with soda or other highly processed carbonated liquids.
Choice D rationale
Lubricating the skin with petroleum-based oils can actually be counterproductive for skin health in some contexts. These heavy oils can clog pores and trap moisture against the skin, leading to maceration, which makes the skin more fragile and prone to breakdown. While moisturization is important, it is better to use pH-balanced emollients or barrier creams specifically designed for pressure injury prevention. Additionally, petroleum products can degrade certain medical materials and increase the risk of sliding if not applied correctly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["42"]
Explanation
Step 1 is 1.5 liters × 1000 mL = 1500 mL.
Step 2 is 12 hours × 60 min = 720 min.
Step 3 is (1500 mL ÷ 720 min) × 20 gtt/mL = 41.6666 gtts/min.
Step 4 is 42 gtts/min.
Correct Answer is C
Explanation
Choice A rationale
Aluminum hydroxide is an antacid commonly used to neutralize gastric acid in patients with heartburn or peptic ulcers. One of its most frequent side effects is constipation. Regarding stool appearance, aluminum hydroxide usually causes the stool to appear white or speckled with white streaks rather than black. It does not contain the metallic components necessary to produce a dark, tarry appearance in the stool.
Choice B rationale
Antibiotics can significantly alter the composition of the normal gut microbiota, which may lead to changes in stool consistency, such as diarrhea. Certain antibiotics might cause greenish or yellowish stools due to rapid transit time and altered bile metabolism. However, antibiotics do not typically cause stool to become black and tarry. That specific discoloration is usually reserved for substances containing bismuth or heavy metals.
Choice C rationale
Iron supplements are well-known for causing stools to become black or dark green. This occurs because unabsorbed iron in the gastrointestinal tract reacts with hydrogen sulfide produced by bacteria, forming iron sulfide. This chemical reaction results in a dark, tarry appearance that can mimic melena. It is a benign side effect, but nurses must distinguish it from true gastrointestinal bleeding through a guaiac fecal occult blood test.
Choice D rationale
Aspirin is a nonsteroidal anti-inflammatory drug that can cause gastrointestinal irritation and bleeding by inhibiting prostaglandin synthesis, which protects the stomach lining. If aspirin causes a black, tarry stool, it is usually because it has induced an actual upper gastrointestinal bleed. Aspirin itself does not possess pigmenting properties that turn stool black without the presence of digested blood, unlike iron or bismuth.
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