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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin.
B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness.
C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact.
D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.
Correct Answer is C
Explanation
A. Oranges is incorrect. Oranges are not a choking hazard as long as they are peeled and cut into small pieces for a toddler. The nurse should not include oranges in a list of choking hazards for toddlers.
B. Potatoes is incorrect. Potatoes themselves are not a choking hazard for toddlers, though whole or large pieces could pose a risk. The risk comes from how the food is prepared, not the food itself. If properly cooked and mashed or cut into small pieces, potatoes are safe.
C. Grapes is correct. Grapes are a common choking hazard for toddlers because they are small, round, and can easily block the airway if not properly cut into small pieces. The nurse should definitely include grapes in the pamphlet as a choking hazard.
D. Corn is incorrect. Corn kernels are not typically a choking hazard for toddlers unless they are served as whole kernels, which could pose a risk if not chewed properly. However, corn in the form of pureed corn or small pieces is safe for toddlers to eat.
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