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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 ["A","B","C","E"]

Explanation

Choice A rationale:

Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.

Choice B rationale:

Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.

Choice C rationale:

Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.

Choice D rationale:

Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.

Choice E rationale:

Diminished lung function can reduce oxygen supply to tissues, slowing healing.

A. The patient has to be repositioned for the bed to be changed. B. Shearing is more likely from wet sheets. C. The moisture creates an environment suitable for the growth of microorganisms in a wound. D. Greater pressure is exerted by a wet bed.

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.

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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?