A nurse is caring for a client who is at risk for a pressure injury.
Which of the following actions should the nurse take?
Massage the client's bony prominences.
Reposition the client every 4 hr.
Elevate the head of the client's bed 45°.
Provide the client with a high-calorie diet.
The Correct Answer is D
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.
Choice B rationale:
These dressings do not have antimicrobial properties.
Choice C rationale:
While these dressings can be left in place for several days, it is not their major purpose.
Choice D rationale:
Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pads are not designed to minimize pain during dressing changes.
Choice B rationale:
Hydrogel dressings are known to minimize pain during dressing changes.
Choice C rationale:
Wet-to-dry dressings can cause discomfort during dressing changes.
Choice D rationale:
Dry gauze can stick to the wound bed and cause pain during dressing changes.
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