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 A
Explanation
A. Offer a wet washcloth for the client to wash their face: Washing the face with a wet washcloth can promote relaxation and help signal to the body that it’s time to wind down. This calming routine can be soothing and may help improve the client’s ability to fall asleep.
B. Perform range-of-motion exercises: Doing range of motion exercises shortly before bedtime can be overstimulating. Physical activity close to bedtime may increase alertness and make it harder for the client to fall asleep.
C. Prepare hot cocoa or tea for the client: While warm drinks might seem comforting, caffeine in some teas or high sugar in hot cocoa can interfere with sleep. It’s important to avoid stimulants and opt for calming beverages, such as caffeine-free herbal teas, instead.
D. Provide a late supper: A large meal late at night can be disruptive to sleep as it may cause indigestion or discomfort. It’s better to encourage lighter, earlier meals to prevent any disturbances that could affect the client’s ability to fall asleep.
Correct Answer is B
Explanation
A. Notify the primary care provider: Notifying the provider is important, but first, the nurse should assess the client’s condition by obtaining vital signs. This helps determine if immediate intervention is needed, like administering antidotes or treatments.
B. Obtain the client's vital signs: The first step is assessing the client’s physical status by checking vital signs. This helps identify signs of toxicity or immediate adverse effects from the overdose, guiding further actions.
C. Educate the client about potential adverse effects: Education is important, but it’s not the first priority in the case of an overdose. The nurse should first focus on assessing and stabilizing the client before providing information on potential adverse effects.
D. Complete an incident report: While an incident report is necessary, it is not the immediate priority. The nurse must first ensure the client’s safety and health by assessing and managing the overdose.
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