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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:

An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.

Choice B rationale:

An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.

Choice C rationale:

A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.

Choice D rationale:

A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.

A. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

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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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A nurse is caring for a client who is at risk for a pressure injury.
Which of the following actions should the nurse take?