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
A pneumothorax is a collapsed lung that occurs when air leaks into the space between the lung and the chest wall.
This can cause diminished breath sounds on the affected side. Distended neck veins are not a symptom of pneumothorax.
B) Itching over the incision is not a symptom of pneumothorax.
C) Irregular heart rate is not a symptom of pneumothorax.
Correct Answer is {"xRanges":[101.765625,141.765625],"yRanges":[263.609375,303.609375]}
Explanation
A pericardial friction rub is highly specific for acute pericarditis and is generally heard over the left sternal border.
It is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward.
Choice A is not the answer because it does not correspond to the left sternal border.
Choice B is not the answer because it does not correspond to the left sternal border.
Choice D is not the answer because it does not correspond to the left sternal border.
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