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

Keep the head of the client’s bed elevated to 45

Provide the client with a high-calorie diet.

Massage the client’s bony prominences.

Reposition the client every 4 hr.

Answer and Explanation

The Correct Answer is B

A) Keep the head of the client’s bed elevated to 45 degrees:
Elevating the head of the bed to 45 degrees can actually increase the risk of pressure injuries, particularly in clients who are already at risk. This position can cause shearing forces and increase pressure on areas such as the sacrum, heels, and hips, making it more likely for pressure ulcers to develop.

B) Provide the client with a high-calorie diet:
A high-calorie diet is important for clients at risk of pressure injuries because adequate nutrition supports skin integrity and wound healing. Clients at risk for pressure injuries often have compromised nutritional status, and providing sufficient calories, protein, and other nutrients helps improve tissue regeneration and resilience. A high-calorie, high-protein diet helps prevent further breakdown of the skin and supports the healing process for any existing wounds.

C) Massage the client’s bony prominences:
Massaging bony prominences, such as the heels, elbows, and sacrum, is not recommended because it can cause tissue damage and increase the risk of pressure injury. Instead, the focus should be on minimizing pressure on these areas and using appropriate methods to redistribute pressure, such as repositioning the client or using pressure-relieving devices.

D) Reposition the client every 4 hours:
Repositioning the client every 4 hours may not be frequent enough for those at high risk for pressure injuries. For individuals who are immobile or at high risk, repositioning should typically occur at least every 2 hours to alleviate pressure on vulnerable areas of the body.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Clean the skin near the drain in a circular motion from the outside to the inside:
When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

B) Empty the drainage device when it is half full:
For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

C) Place a perforated gauze pad around the drain to absorb drainage:
A Penrose drain is an open drain that allows drainage of fluids from a wound or surgical site. A perforated gauze pad should be placed around the drain to absorb the drainage and keep the surrounding area clean and dry. This helps prevent infection and maintains a sterile environment around the wound.

D) Connect the drain to continuous low-pressure suction:
A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

A. Diaphoresis B. Weight loss C. Hypotension D. Tachycardia

Correct Answer is D

Explanation

A) Diaphoresis:
While diaphoresis (excessive sweating) may occur with some cardiac or respiratory conditions, it is not a primary or expected sign of circulatory overload. Circulatory overload generally involves fluid accumulation in the body, and symptoms are more likely related to fluid retention and increased workload on the heart rather than sweating.

B) Weight loss:
Weight loss is not typically associated with circulatory overload. In fact, one of the hallmark signs of circulatory overload is weight gain due to fluid retention. The body retains excess fluid in the vascular system, leading to an increase in weight rather than weight loss.

C) Hypotension:
Hypotension (low blood pressure) is generally not associated with circulatory overload. Circulatory overload typically results in elevated blood pressure due to the increased volume of circulating fluid. In some cases, if the heart is unable to handle the increased volume, symptoms like pulmonary edema or shortness of breath can occur, but hypotension is more commonly seen in conditions like shock or severe fluid loss.

D) Tachycardia:
Tachycardia (an elevated heart rate) is a common finding in circulatory overload. When there is an excess of fluid in the body, the heart has to work harder to pump the additional volume of blood, leading to an increased heart rate. This is a compensatory response to the increased workload on the heart. It is also a sign that the body is attempting to maintain adequate tissue perfusion despite the excess fluid volume.

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

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