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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.
B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.
C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.
D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.
Correct Answer is C
Explanation
A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.
B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.
C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.
D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.
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