A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

Check the client's skin every 4 hr.

Place a donut-shaped cushion under the client.

Turn the client every/hr.

Place the client in a 30° lateral position.

Answer and Explanation

The Correct Answer is D

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

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Correct Answer is A

Explanation

A. Bleach: This is correct. Bleach (sodium hypochlorite. is recommended for disinfecting surfaces contaminated with blood or other body fluids due to its ability to effectively kill bloodborne pathogens, including HIV, which is crucial in a healthcare setting involving AIDS. The CDC recommends a solution of 1:10 dilution of bleach to water for blood spill clean-up.

B. Isopropyl alcohol: This is incorrect. While isopropyl alcohol can disinfect surfaces, it is not as effective as bleach in killing certain viruses, including HIV, in blood spills. It may not be sufficient for complete disinfection after a blood spill.

C. Chlorhexidine: This is incorrect. Chlorhexidine is an antiseptic commonly used for skin disinfection, not for cleaning contaminated surfaces. It is not recommended for disinfecting blood spills.

D. Hydrogen peroxide: This is incorrect. Hydrogen peroxide can be used for cleaning, but it is not as effective as bleach in eliminating certain pathogens like HIV after a blood spill. It also may not have the broad-spectrum disinfecting power needed for bloodborne pathogens.

A. Limit the number of choices for the client. B. Use written signs to assist the client with locating the bathroom. C. Provide a stimulating environment for the client. D. Use confrontation to manage the client’s behavior.

Correct Answer is A

Explanation

A. Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as "Would you like tea or juice?" instead of an open-ended question, helps reduce confusion and frustration.

B. Using written signs to assist with locating the bathroom is incorrect. While cues can be helpful, clients with Alzheimer's disease often experience difficulty processing written information as the disease progresses. Using pictures or symbols instead of words is more effective.

C. Providing a stimulating environment for the client is incorrect. An overly stimulating environment can increase agitation and confusion. A calm, structured setting with minimal distractions is better for clients with Alzheimer's disease.

D. Using confrontation to manage the client’s behavior is incorrect. Confronting or arguing with a client who has Alzheimer's disease can lead to increased agitation and distress. Instead, caregivers should use redirection and reassurance to manage behaviors effectively.

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A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

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