A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact.
Which of the following interventions should the nurse include in the plan of care?
Apply an occlusive dressing.
Turn and reposition the client every 4 hr.
Support bony prominences with pillows.
Massage the reddened areas three times daily.
The Correct Answer is C
The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The fluctuation of fluid in the water-seal chamber of a chest tube is known as tidaling and is caused by the changes in pressure within the chest during respiration.
Choice A is not correct because tidaling does not indicate an air leak.
Choice B is not correct because tidaling does not necessarily mean that the lung is fully re-expanded.
Choice D is not correct because suction pressure does not cause tidaling.
Correct Answer is C
Explanation
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
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