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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 B

Explanation

Choice A rationale:

Numbing the area treated is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice B rationale:

Dilating the blood vessels is the correct answer. Moist heat therapy works by increasing the temperature of the skin/soft tissue, which leads to vasodilation and increased blood flow to the treated area.

Choice C rationale:

Drawing fluid to the site of application is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice D rationale:

Constricting the blood vessels is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area through vasodilation.

A. From the left to the right across the wound. B. From the outer abdomen toward the wound. C. In a circular motion around the wound, circling to the outside. D. Directly over the wound.

Correct Answer is C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Moist heat has the physiological effect of:

Correct Answer is B

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?