A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
Reposition the client every 2 hr.
Elevate the head of the client's bed 45°
Massage the client's bony prominences.
Provide the client with a high-calorie diet.
The Correct Answer is A
A. Reposition the client every 2 hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.
B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.
B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.
C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.
D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.
Correct Answer is B
Explanation
A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.
B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.
C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.
D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.
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