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 C
Explanation
A. "You shouldn't worry about the future so you can concentrate on getting well.":
This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.
B. "If you work hard on your physical therapy, you won't need to worry.":
While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.
C. "You're concerned about what will happen when you leave the hospital?":
This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.
D. "Why are you concerned even though everyone is here to help you?":
This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.
Correct Answer is B
Explanation
"Most people are scared their first time in a health care facility":
While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.
"We can discuss what you can expect during your stay":
This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.
"You have nothing to worry about. Everything will be fine":
This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.
"Why are you feeling scared about being in this facility?":
While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.
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