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 C
Explanation
Choice A rationale:
Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.
Choice B rationale:
While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.
Choice C rationale:
Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.
Choice D rationale:
A wet bed does not exert greater pressure on the patient’s skin.
Correct Answer is A
Explanation
Choice A rationale:
Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.
Choice B rationale:
Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Choice C rationale:
Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.
Choice D rationale:
Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
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