A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Ensure the client's heels are not touching the mattress.

Massage the client's bony prominences.

Raise the head of the client's bed to a 60° angle.

Reposition the client every 4 hr.

Answer and Explanation

The Correct Answer is A

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

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Correct Answer is D

Explanation

A. "The higher the score, the higher the pressure injury risk.":The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.":The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.":Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements:Sensory perception,Moisture,Activity,Mobility,NutritionandFriction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

A. Cholesterol level B. History of hyperlipidemia C. History of hypertension D. History of rheumatoid arthritis F. Family history

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

Explanation

A. Cholesterol level: Elevated cholesterol levels are a risk factor for heart disease. High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol are associated with an increased risk of cardiovascular disease.

B. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, including cholesterol and triglycerides. A history of hyperlipidemia indicates a pre-existing condition that can contribute to the risk of heart disease.

C. History of hypertension: Hypertension (high blood pressure) is a significant risk factor for heart disease. It can lead to damage to the arteries, increasing the risk of atherosclerosis (narrowing and hardening of the arteries) and other cardiovascular complications.

Explanation:

D. History of rheumatoid arthritis: While rheumatoid arthritis is an autoimmune condition that primarily affects the joints, it is not a direct risk factor for heart disease. However, people with rheumatoid arthritis may have an increased risk of cardiovascular disease due to inflammation.

E. Fasting glucose level: The fasting glucose level is related to diabetes rather than heart disease. However, diabetes is a significant risk factor for heart disease, so managing glucose levels is crucial for overall cardiovascular health.

F. Family history: While a family history of heart disease can contribute to an individual's overall risk, it is not a direct finding in the medical record that places the client at risk. The specific risk factors mentioned earlier (cholesterol level, history of hyperlipidemia, and history of hypertension) are more direct indicators of cardiovascular risk.

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A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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

Explanation

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