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:
Reconstruction is incorrect because it is not the second stage of wound healing.
Choice B rationale:
Maturation is incorrect because it is not the second stage of wound healing.
Choice C rationale:
Proliferation is incorrect because it is not the second stage of wound healing.
Choice D rationale:
Inflammation is the correct answer because it is the second stage of wound healing.
Correct Answer is D
Explanation
Choice A rationale:
Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.
Choice B rationale:
Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.
Choice C rationale:
Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.
Choice D rationale:
Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.