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.
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 D
Explanation
A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.
B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.
C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.
D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.
Correct Answer is A
Explanation
A. "Eating a high fiber diet will reduce my risk for developing skin cancer." There is no evidence that a high-fiber diet specifically reduces the risk of skin cancer. This statement indicates a misunderstanding and a need for further teaching.
B. "I should check my skin monthly for any changes." Regular self-examinations are recommended to detect early signs of skin cancer.
C. "I should use sunscreen even on cloudy days." UV rays can penetrate clouds, so using sunscreen on cloudy days is an important preventive measure.
D. "I should avoid the use of tanning booths." Tanning booths increase the risk of skin cancer, so avoiding them is a correct preventive action.
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