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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "It's nice having other people cook for me.":

This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.

B. "I've never been the kind of person to ask others for help.":

This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.

C. "I'm looking forward to being able to be independent again.":

This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.

D. "I really don't know what I'm supposed to do all day.":

This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.

A. "I will move your joints to the point of mild pain." B. "I will repeat these movements 3 to 5 times." C. "These movements will be performed once per day." D. "I will move your joints quickly."

Correct Answer is B

Explanation

A. "I will move your joints to the point of mild pain":

This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.

B. "I will repeat these movements 3 to 5 times":

This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.

C. "These movements will be performed once per day":

This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.

D. "I will move your joints quickly":

This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?

Correct Answer is A

Explanation

A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?

A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take?

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)