A client is bedridden and appears to be frail and malnourished. Which nursing interventions will most effectively prevent skin injury? (Select all that apply.)
Cleansing the skin routinely after soiling occurs.
Applying moisturizer to dry areas of skin.
Using a Hoyer lift for all transfers.
Massaging the client’s reddened shoulders and heels.
Repositioning the client once per shift.
Correct Answer : A,B,C
Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.
Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.
Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.
Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.
Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.
Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.
Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.
Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.
Correct Answer is B
Explanation
Choice A reason: The main side effect of acetaminophen is gastrointestinal (GI) bleeding is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Acetaminophen is a pain reliever and fever reducer that is commonly used for osteoarthritis, but it does not have antiinflammatory properties. Acetaminophen does not cause GI bleeding, unlike NSAIDs, which can irritate the stomach lining and increase the risk of ulcers and bleeding. The main side effect of acetaminophen is liver damage, which can occur if the dose is exceeded or if the drug is combined with alcohol or other hepatotoxic substances.
Choice B reason: You should not take more than 4000 mg of acetaminophen a day is a teaching that the nurse should include in the education, because it is correct and important. Acetaminophen has a maximum daily dose of 4000 mg for adults, which should not be exceeded to avoid the risk of liver damage or overdose. Acetaminophen can be found in many overthecounter and prescription products, such as cold and flu remedies, cough syrups, or combination analgesics. Therefore, the client should read the labels carefully and keep track of the total amount of acetaminophen they are taking from all sources.
Choice C reason: Nonsteroidal antiinflammatory drugs (NSAIDs) are very safe and have no side effects is not a teaching that the nurse should include in the education, because it is incorrect and misleading. NSAIDs are a group of drugs that have antiinflammatory, analgesic, and antipyretic effects, and that are commonly used for osteoarthritis. However, NSAIDs are not very safe and have many side effects, such as GI bleeding, ulcers, kidney damage, cardiovascular events, allergic reactions, or interactions with other drugs. Therefore, the client should use NSAIDs with caution and under the supervision of the provider.
Choice D reason: The most common adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs) are liver failure and tinnitus is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Liver failure and tinnitus are not the most common adverse effects of NSAIDs, but rather rare and serious ones. Liver failure can occur in some cases of NSAID overdose or hypersensitivity, while tinnitus can occur in some cases of NSAID toxicity or high doses. The most common adverse effects of NSAIDs are GI bleeding, ulcers, or irritation, which can affect up to 15% of the users.
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