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?

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

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

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

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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Correct Answer is ["B","C","D"]

Explanation

A. Pain medication administration: Pain medications, while necessary, do not directly increase the risk of dehiscence.

B. Poor nutritional state: Adequate nutrition is essential for wound healing. Malnutrition can weaken tissue strength and delay healing.

C. Wound infection: Infection can weaken the tissue at the wound site, increasing the risk of dehiscence.

D. Obesity: Excess body weight can put pressure on the wound, making it more likely to open.

E. Altered mental status: This does not directly increase the risk of wound dehiscence.

A. Avoid crowds B. Eat plenty of fresh fruits and vegetables C. Take temperature weekly. D. Perform mild exercise, such as gardening

Correct Answer is A

Explanation

A. Avoid crowds - Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens.

B. Eat plenty of fresh fruits and vegetables - While generally healthy, fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Cooked or properly washed and peeled produce is safer.

C. Take temperature weekly - Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early.

D. Perform mild exercise, such as gardening - Gardening can expose individuals to soil-borne organisms that could lead to infections. Indoor exercises or those that don’t involve potential pathogen exposure are safer.

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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?

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Correct Answer is A

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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?