A nurse is caring for a client who is immobile and developing skin breakdown. Which of the following actions should the nurse take?
Bathe the client with soap and hot water.
Massage bony prominences four times daily.
Keep the head of the client's bed at 30° or less.
Slide the client up in bed every 2 hr.
The Correct Answer is C
A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.
B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.
C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.
D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use a padded tongue blade to protect the client's tongue while seizing: A tongue blade should not be used during a seizure, as it can cause injury to the client. The client’s airway should be protected by positioning them correctly, not by inserting objects into their mouth.
B. Place the client in a supine position during the seizure: The client should not be placed in a supine position during a seizure due to the risk of aspiration. Instead, the client should be placed on their side to help maintain an open airway and prevent aspiration.
C. Monitor the client's respiratory and cardiac status: During a tonic-clonic seizure, respiratory and cardiac monitoring are crucial. Seizures can lead to decreased oxygenation, irregular heart rhythms, and other complications.
D. Offer the client a cup of juice to drink once the seizure is over: After a seizure, the client may have impaired swallowing reflexes, and offering liquids too soon can cause aspiration. The nurse should assess the client’s ability to swallow before offering fluids.
Correct Answer is B
Explanation
A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.
B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.
C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.
D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.
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