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 B

Explanation

A. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

B. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

C. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

D. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

A. "The higher the score, the higher the pressure injury risk." B. The client's age is part of the measurement." C. "Each element has a range from one to five points." D. "The scale measures six elements."

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.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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