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A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

A.

instruct the client to dig their heels into the bed to push themselves upwards.

B.

Assist the client with a trapeze to raise their body while staff assists with repositioning

C.

Have two to three staff members pull the client up in bed when needed.

D.

Elevate the head of the bed 90° for bedridden clients.

Answer and Explanation

The Correct Answer is B

A. Instruct the client to dig their heels into the bed to push themselves upwards: This increases friction on the heels, which can lead to skin breakdown.

B. Assist the client with a trapeze to raise their body while staff assists with repositioning. Using a trapeze allows the client to lift themselves slightly off the bed, reducing the friction and shear forces that can cause skin injuries during repositioning.

C. Have two to three staff members pull the client up in bed when needed: This increases the risk of friction injuries, especially if the client is not lifted properly.

D. Elevate the head of the bed 90° for bedridden clients: High elevation of the bed can increase the risk of shear injuries due to sliding down in bed.


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Related Questions

Correct Answer is C

Explanation

A. Packed RBCs - These are used to treat anemia or significant blood loss but do not address the clotting deficiency in hemophilia.

B. Fresh frozen plasma - This contains all clotting factors, but in hemophilia A, specifically replacing factor VIII is more effective and targeted.

C. Recombinant - Recombinant factor VIII is a synthetic form of the clotting factor that patients with hemophilia A are deficient in. It is used to increase factor VIII levels before procedures to prevent excessive bleeding.

D. Prophylactic antibiotics - These are used to prevent infection but do not help in managing the bleeding risks associated with hemophilia.

Correct Answer is []

Explanation

Condition:

  • Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

  1. Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
  2. Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

  1. Weight (B): Monitor weight to assess for fluid retention and overload.
  2. Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

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