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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:

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.

A. Using a thermometer to check the temperature of the pad. B. Securing the pad to the patient. C. Assisting the patient to lie on top of the pad. D. Instructing the patient not to sleep on the pad. E. Inspecting the plug and cord for cracks or fraying.

Correct Answer is ["A","B","D","E"]

Explanation

E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.

Choice A rationale:

It’s important to check the temperature of the pad to prevent burns.

Choice B rationale:

Securing the pad ensures it stays in place and provides consistent heat.

Choice C rationale:

Patients should not lie on top of the pad as it can lead to burns.

Choice D rationale:

Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.

Choice E rationale:

Inspecting the plug and cord prevents electrical hazards.

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