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 ["A","C","E"]

Explanation

A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.

B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.

C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.

D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.

E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.

A. Lie on your back when sleeping. B. Wash your hair 24 hr after surgery. C. Resume your exercise routine. D. Eat foods that are soft

Correct Answer is D

Explanation

A. Lie on your back when sleeping - While specific sleeping positions might be recommended, lying on the back is not necessarily required unless specified by the surgeon.

B. Wash your hair 24 hr after surgery - Hair washing is usually advised against within the first 24-48 hours post-surgery to prevent infection and avoid disturbing the surgical site.

C. Resume your exercise routine - Exercise is typically restricted initially to prevent strain or injury to the surgical area.

D. Eat foods that are soft - Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging any packing or stitches, and promote comfort during the initial healing period.

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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

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