Which interventions can reduce the incidence of pressure injuries in hospitalized clients? (Select all that apply)
Frequent skin assessments
Frequent turning and positioning
Optimizing nutrition
Maintaining the head of the bed at a 45-degree angle
Inspect the sacrum for blanching
Correct Answer : A,B,C
Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity.
Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion.
Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity.
Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces.
Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Collecting sputum specimens for acid-fast bacilli (AFB) testing over three consecutive mornings is critical for diagnosing active tuberculosis. AFB smear and culture detect Mycobacterium tuberculosis in sputum, confirming pulmonary TB. Morning samples yield higher bacterial loads, improving diagnostic sensitivity, as the bacteria accumulate overnight in the respiratory tract.
Choice B reason: Monitoring vital signs every shift is important for assessing patient stability but does not directly aid in diagnosing active tuberculosis. Fever or tachycardia may suggest infection, but these are non-specific and not confirmatory. Diagnostic tests like AFB, imaging, or serology are needed to identify Mycobacterium tuberculosis as the cause of symptoms.
Choice C reason: Ordering a complete blood count, basic metabolic panel, HIV viral load, and VDRL supports TB diagnosis. CBC may show anemia or leukocytosis, BMP assesses organ function, HIV testing identifies immunosuppression increasing TB risk, and VDRL rules out syphilis, which can mimic TB symptoms. These provide a comprehensive diagnostic workup.
Choice D reason: A chest X-ray is essential for diagnosing active pulmonary tuberculosis. It reveals characteristic findings like cavitary lesions, infiltrates, or hilar lymphadenopathy in the lungs. These radiographic signs, combined with clinical symptoms and AFB testing, confirm the presence of active TB, particularly in patients with cough and weight loss.
Choice E reason: Admitting the patient to a negative pressure room is crucial for diagnosing and managing suspected active TB. It prevents airborne transmission of Mycobacterium tuberculosis to others, ensuring safety while diagnostic tests like AFB and chest X-ray are conducted. This isolation is standard for suspected infectious TB cases.
Correct Answer is D
Explanation
Choice A reason: A nasal cannula at 2 L/min delivers low-flow oxygen (24-28% FiO2), insufficient for a COPD exacerbation, where hypoxemia is severe due to airway obstruction and ventilation-perfusion mismatch. It cannot provide precise, high FiO2 needed to correct hypoxia while avoiding excessive oxygen, which may suppress respiratory drive in COPD patients.
Choice B reason: A simple face mask at 10 L/min delivers 40-60% FiO2 but lacks precision in oxygen concentration. In COPD, excessive oxygen can reduce respiratory drive, causing CO2 retention due to the hypoxic drive mechanism. This makes it less suitable than a Venturi mask, which provides controlled oxygen delivery.
Choice C reason: A non-rebreather mask at 15 L/min delivers near 100% FiO2, which is excessive for COPD exacerbation. High oxygen levels can suppress the hypoxic drive in COPD patients, leading to hypercapnia and respiratory failure. Controlled oxygen delivery is needed to balance oxygenation and CO2 retention risks.
Choice D reason: A Venturi mask at 40% FiO2 delivers precise oxygen concentrations, ideal for COPD exacerbations. It balances hypoxemia correction with the risk of CO2 retention by providing controlled FiO2. This prevents suppression of the hypoxic respiratory drive while ensuring adequate oxygenation, making it the preferred method for acute COPD management.
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