A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk of a friction and shear injury?
Postpone daily bed bath
Elevate the client’s head of the bed to 45 degrees
Caregiver independently slides the client up in bed
Use a mechanical lift to reposition the client every 2 hours
The Correct Answer is D
Choice A reason: Postponing daily bed bath is not appropriate for reducing the risk of a friction and shear injury. Bed bath is a hygiene measure that helps to keep the skin clean and dry and prevent infection. Friction and shear are caused by the rubbing and pulling of the skin against the bed surface, not by the bed bath itself.
Choice B reason: Elevating the client’s head of the bed to 45 degrees is not appropriate for reducing the risk of a friction and shear injury. In fact, this may increase the risk as the client may slide down the bed due to gravity and cause more friction and shear on the skin. The head of the bed should be kept at the lowest possible angle, preferably less than 30 degrees, unless contraindicated by the client’s condition.
Choice C reason: Caregiver independently slides the client up in bed is not appropriate for reducing the risk of a friction and shear injury. This may cause more damage to the skin as the caregiver may exert excessive force and drag the client’s skin along the bed surface. The caregiver should use a draw sheet or a slide board to lift and reposition the client with the help of another person.
Choice D reason: Use a mechanical lift to reposition the client every 2 hours is the most appropriate intervention for reducing the risk of a friction and shear injury. A mechanical lift is a device that helps to transfer and reposition the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the caregiver from injuring themselves by lifting the client manually. The client should be repositioned every 2 hours to relieve the pressure on the skin and prevent pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I will use a humidifier during the winter months." is not the correct answer, because it indicates a good understanding of dry skin. Using a humidifier during the winter months is a helpful measure to prevent or treat dry skin, as it can increase the moisture level in the air, which can hydrate the skin and reduce the loss of natural oils.
Choice B reason: "I will shower every day in hot water." is the correct answer, because it indicates a need for further teaching about dry skin. Showering every day in hot water is a harmful practice that can worsen dry skin, as it can strip the skin of its natural oils, damage the skin barrier, and cause irritation and inflammation.
Choice C reason: "I will avoid tight belts." is not the correct answer, because it indicates a good understanding of dry skin. Avoiding tight belts is a helpful measure to prevent or treat dry skin, as it can reduce the friction and pressure on the skin, which can prevent skin breakdown and infection.
Choice D reason: "I will drink at least 3000 mL of water daily." is not the correct answer, because it indicates a good understanding of dry skin. Drinking at least 3000 mL of water daily is a helpful measure to prevent or treat dry skin, as it can hydrate the body and the skin, and flush out toxins and waste products.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.
Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.
Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.
Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.
Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.
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