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 A
Explanation
Administering IV fluids can help maintain blood flow to the kidneys and prevent acute kidney failure.
Choice B is incorrect because inserting a urinary catheter does not prevent acute kidney failure.
Choice C is incorrect because an intravenous pyelogram is a diagnostic test and does not prevent acute kidney failure.
Choice D is incorrect because beta-blocker therapy is not used to prevent acute kidney failure.
Correct Answer is A
Explanation
“You should ask your provider about your plan.” The client has expressed a preference for trying vitamins and minerals instead of chemotherapy.
The nurse should encourage the client to discuss their treatment plan with their provider to ensure that they receive the most appropriate care.
Choice B is not the correct answer because while it is important for the client to be informed about their treatment options, the nurse’s primary responsibility is to encourage the client to discuss their concerns with their provider.
Choice C is not the correct answer because it is not within the nurse’s scope of practice to make definitive statements about the effectiveness of holistic treatments.
Choice D is not the correct answer because it is not within the nurse’s scope of practice to make definitive statements about the best way to treat cancer.
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