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 A

Explanation

A. Endolymph fluid provides protection to the structures of the inner ear. - Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance.

B. Sanguineous fluid provides protection to the structures of the inner ear - Sanguineous fluid refers to blood or fluid containing blood. It is not present in the inner ear.

C. Aqueous humor provides protection to the structures of the inner ear - Aqueous humor is the fluid found in the eye, not the ear.

D. Vitreous humor provides protection to the structures of the inner ear - Vitreous humor is found in the eye, not the ear.

A. Stop the infusion of blood, B. Inform the provider. C. Obtain a urine specimen. D. Notify the laboratory.

Correct Answer is A

Explanation

A. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.

B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.

C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.

D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.

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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 teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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