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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:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

A. Test the temperature of the solution. B. Use only sterile equipment and solution. C. Position the patient comfortably. D. Soak only the affected area.

Correct Answer is A

Explanation

Choice A rationale:

Testing the temperature of the solution is crucial to prevent burns.

Choice B rationale:

While using sterile equipment and solution is important, it’s not the most important in a hot soak treatment.

Choice C rationale:

Comfort is important but not as critical as preventing burns.

Choice D rationale:

Soaking only the affected area is good practice but not as vital as preventing burns.

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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

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?