A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?
Reposition the client every 3 hours.
Apply cornstarch to keep the skin dry.
Provide the client with a diet high in protein.
Massage bony prominences to promote circulation.
The Correct Answer is C
A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
Correct Answer is D
Explanation
It would be inappropriate to delegate the unsupervised task of transferring a client from bed to chair to an unlicensed assistant (UAP) if it was the client's first time out of bed after surgery. In this situation, the client may have specific needs or limitations that require the expertise and assessment of a licensed healthcare provider. The nurse should supervise the transfer to ensure that it is performed safely and appropriately for the client's condition.
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