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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?

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Karaya paste is used for ostomy care, not for dressing changes.

Choice B rationale:

Paper tape might not provide the necessary adhesion for frequent dressing changes.

Choice C rationale:

Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.

Choice D rationale:

Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.

A. Supine with the head tilted toward the right eye. B. Upright with the head tilted toward the left eye. C. Upright with the head hyperextended. D. Supine with the head hyperextended.

Correct Answer is A

Explanation

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

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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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Correct Answer is A

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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?