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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.
B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.
C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.
D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.
E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.
Correct Answer is A
Explanation
A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.
B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.
C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.
D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.
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