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 B
Explanation
A. "You need to understand that you have very little time left":
This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.
B. "I will contact your provider to discuss your options":
This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan
C. "Enjoy the time you have and do the things you want to do":
This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.
D. "Hospice care is the best thing for you at this time":
While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.
Correct Answer is C
Explanation
A. Four-point alternating gait:
This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.
B. Swing-through gait:
The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.
C. Three-point gait:
This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.
D. Two-point alternating gait:
In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.
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