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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.

B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.

C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.

D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.

A. Choose orange juice instead of apple juice. B. Replace sugar with molasses when baking. C. Avoid using salt substitutes when cooking. D. Eat granola for breakfast.

Correct Answer is C

Explanation

A. Choose orange juice instead of apple juice:
Explanation: Orange juice is a source of potassium, so this choice would not be appropriate for a low potassium diet.

B. Replace sugar with molasses when baking:
Explanation: Molasses is a good alternative to sugar and does not contribute significantly to potassium intake, making it suitable for a low potassium diet.

C. Avoid using salt substitutes when cooking:
Explanation: Salt substitutes often contain potassium chloride, which can increase potassium intake. Therefore, it's advisable to avoid them on a low potassium diet.

D. Eat granola for breakfast:
Explanation: Granola can be a good source of potassium, so it may not be suitable for someone on a low potassium diet.

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A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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