A nurse is caring for a child in the PICU. To prevent pressure ulcers, which intervention should the nurse include in the child's plan of care?
Avoid the use of a draw sheet when turning
Post a turning schedule at the client's bedside
Vigorously massage lotion into bony prominences
Turn and reposition the client at least every 4 hours
The Correct Answer is B
Turning and repositioning the client at regular intervals is essential for preventing pressure ulcers in pediatric clients, especially those in the PICU who may be immobilized or have limited mobility due to their condition or treatment. Repositioning helps relieve pressure on bony prominences and redistributes pressure on the skin, reducing the risk of pressure ulcers. Turning schedules should be individualized based on the child's condition, mobility, and risk factors for pressure ulcers.
A. Avoid the use of a draw sheet when turning: Using a draw sheet can facilitate safe and smooth turning of the client without causing shear or friction forces. It helps distribute the weight evenly and reduces the risk of injury to the client or caregiver during the turning process. Therefore, avoiding the use of a draw sheet may increase the risk of pressure ulcers rather than prevent them.
B. Post a turning schedule at the client's bedside: While posting a turning schedule may serve as a reminder for staff, it alone does not provide direct intervention to prevent pressure ulcers. The crucial aspect is implementing the turning schedule consistently and ensuring that the client is repositioned at appropriate intervals.
C. Vigorously massage lotion into bony prominences: Massaging lotion into bony prominences can increase friction and shear forces on the skin, potentially causing tissue damage rather than preventing pressure ulcers. Additionally, vigorous massage may be uncomfortable or painful for the client, especially if they have fragile skin or existing pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assesssing the child with suspected or confirmed Wilm's tumor, it is important to avoid palpation of the abdomem. This is because it can lead to dislodging of the tumor cells
Correct Answer is B
Explanation
A. Application of antibiotic ointment to the pin sites is not necessary as pins drilled into the bone are not used in buck extension traction.
B. Traction can be removed briefly during baths in cases where a pre-made boot is being used
C. Adequate hydration is essential for overall health and well-being, and fluid restriction could lead to dehydration, especially in a child with increased metabolic demands due to illness or injury.
D. Repositioning every 2 hours may not be necessary, as the child's position is generally stable with the traction device in place.
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