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

Explanation

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow." This describes acute angle-closure glaucoma, not retinal detachment.

B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." Retinal detachment happens when the retina separates from its supporting tissues, including the blood vessels, leading to vision loss.

C. "Vision changes occur when the retina begins to break down and collect bits of debris." This describes age-related macular degeneration, not retinal detachment.

D. "Vision changes occur when the cloudy lens alters the passage of light through the eye." This describes cataracts, not retinal detachment.

A. Airway obstruction B. Paralytic ileus C. infection D. Fluid imbalance

Correct Answer is A

Explanation

A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.

B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.

C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.

D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.

View Question and Answer

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

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