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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 C

Explanation

Choice A rationale:

Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.

Choice B rationale:

It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.

Choice C rationale:

Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.

Choice D rationale:

Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.

A. applying hydrocolloids to the wound bed. B. placing a transparent dressing over the pressure injury. C. pulsating lavage. D. using a topical enzyme solution in the wound bed.

Correct Answer is C

Explanation

Choice A rationale:

Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.

Choice B rationale:

Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.

Choice C rationale:

Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.

Choice D rationale:

Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.

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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

When applying an ice pack, it is necessary to:

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?