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 D
Explanation
Initiate a referral for the client to a home health agency.
This action demonstrates client advocacy because it empowers the client to continue self-care at home while also providing them with additional support and resources through the home health agency.
Choice A is wrong because avoiding large crowds of people is a precautionary measure but does not demonstrate client advocacy.
Choice B is wrong because avoiding raw vegetables is a dietary recommendation but does not demonstrate client advocacy.
Choice C is wrong because reminding the client of the importance of medication adherence is important but does not demonstrate client advocacy.
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching because headache is a common symptom of anemia.
Choice B is incorrect because bradycardia (slow heart rate) is not a common symptom of anemia.
Instead, anemia can cause irregular heartbeats or a fast heartbeat.
Choice Dis incorrect because flushed skin color is not a common symptom of anemia.
Instead, anemia can cause pale or yellowish skin 1.
Choice Cis incorrect because heat intolerance is not a common symptom of anemia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today