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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.

B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.

C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.

D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.

A. Hemoglobin level B. Fluid intake C. Temperature D. Skin color

Correct Answer is C

Explanation

A. Hemoglobin level:While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.

B. Fluid intake:Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.

C. Temperature:A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.

D. Skin color:Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.

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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

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Correct Answer is C

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