Which nursing intervention is crucial for a client with impaired mobility to prevent skin breakdown on bony prominences?
Apply talcum powder to areas at risk for breakdown.
Encourage the client to drink more fluids.
Use pillows and cushions to support and position the client.
Perform a complete bed bath daily.
The Correct Answer is C
A. Apply talcum powder to areas at risk for breakdown: Talcum powder can cake or clump when mixed with moisture, which can act as an abrasive, causing friction and irritation that leads to skin breakdown.
B. Encourage the client to drink more fluids: This is an important intervention to maintain tissue hydration and perfusion, but it is not the most crucial direct measure to prevent mechanical injury on bony prominences.
C. Use pillows and cushions to support and position the client: Utilizing pillows, wedges, and specialty cushions is critical for proper alignment, redistribution of pressure, and ensuring that bony prominences (like the heels, sacrum, and trochanters) are floating or supported to eliminate skin-to-skin contact and relieve external pressure.
D. Perform a complete bed bath daily: This is a routine personal hygiene measure. While cleanliness is important, it is less crucial than pressure redistribution in the prevention of pressure injuries on bony prominences.
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Related Questions
Correct Answer is A
Explanation
A. Reposition the patient every 2 hours and use pressure redistribution devices:The formation of a Stage I pressure injury means the current pressure relief regimen is inadequate. The immediate priority is to offload the pressure (repositioning every 2 hours or more frequently) and utilize pressure redistribution devices (e.g., specialized mattresses or cushions) to prevent further tissue damage and allow the skin to recover.
B. Apply alcohol-based cream to the area: Alcohol is drying and irritating and can damage the already compromised skin.
C. Elevate the head of the bed to 45°: Elevating the head of the bed above 30 degrees increases shear and friction on the sacrum, which is a major contributing factor to pressure injury formation.
D. Gently rub the area to increase circulation:Massaging a reddened, nonblanchable area can cause further deep tissue injury by damaging capillaries and underlying tissue.
Correct Answer is A
Explanation
A. To prevent shearing of the patient's skin: When a patient is pulled or dragged across a sheet, the deeper tissues (bone and muscle) are stationary while the skin moves, leading to shear injury—one of the primary mechanisms for Deep Tissue Pressure Injuries (DTPIs). Using a lift device raises the patient completely, eliminating this destructive shearing and friction force.
B. To make the repositioning process faster:While a lift device may be efficient, patient safety and skin protection are the clinical priorities, not speed.
C. To prevent the nurse from straining their back: This is an extremely important benefit for nurse safety and injury prevention, but the primary reason the intervention is implemented in the patient's plan of care is for the direct therapeutic benefit of protecting the patient's skin integrity.
D. To ensure the patient is positioned comfortably: This is a secondary benefit. While comfort is considered, the lift device's essential function is mechanical protection of the skin and underlying tissues.
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