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
The correct answer isChoice D.
Choice A rationale:Checking potassium levels is important in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale:Bicarbonate infusion is not the priority intervention in the management of DKA.It is used only in severe cases of metabolic acidosis
Choice C rationale:Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale:Administering 0.9% sodium chloride is the priority intervention in the management of DKA.It is used to restore intravascular volume and correct electrolyte imbalances
Correct Answer is A
Explanation
Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process.
The presence of dark red granulation tissue is a sign that the wound is healing.
B.Light yellow exudate: Light yellow exudate may indicate the presence of infection and is not a sign of healing.
C. Dry brown eschar: Dry brown eschar is dead tissue that needs to be removed for the wound to heal properly.
D.Wound tissue firm to palpation: Wound tissue firm to palpation is not a specific sign of healing.
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