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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer the client's medications one at a time:
This is the correct action. Administering medications one at a time allows the nurse to monitor the client's ability to swallow each medication safely. It minimizes the risk of aspiration and ensures that each medication is swallowed effectively.
B. Encourage the client to use a straw to take the medications:
Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.
C. Give the client's medications between meals:
The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.
D. Assist the client into semi-Fowler's position:
While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.
Correct Answer is A
Explanation
A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.
B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.
C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.
D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.
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