A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)
Massage over erythematous bony prominences.
Minimize skin exposure to moisture.
Use pillows to keep heels off the bed surface.
Implement a turning schedule every 4 hours.
Keep the client's skin dry with powder.
Correct Answer : B,C
The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.
Choice A reason:
a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.
Choice B reason:
b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.
Choice C reason:
c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.
Choice D reason:
d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.
Choice E reason:
e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason:
The statement "The client is Black" does not contribute to the risk of chlamydia based on race alone. Chlamydia infection rates are influenced by a variety of factors, including access to healthcare and socioeconomic status, rather than race itself.
Choice B reason:
Having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs) like chlamydia because it raises the likelihood of exposure to an infected partner.
Choice C reason:
While being male is not a risk factor in itself, men who have sex with men (MSM) are at a higher risk for STIs like chlamydia due to biological and behavioral factors that facilitate transmission.
Choice D reason:
Engaging in sexual activities with men is a known risk factor for chlamydia among MSM due to the higher prevalence of this STI within this group.
Choice E reason:
The age of 37 does not specifically contribute to the risk of chlamydia. However, chlamydia is more commonly diagnosed in younger individuals, typically those under 25 years old, due to higher rates of new and multiple sexual partnerships.
Correct Answer is B
Explanation
Choice A reason:
While monitoring urinary output is important after surgery to ensure kidney function and that the urinary tract has not been compromised during surgery, it is not the immediate priority. The nurse should ensure that the client is not experiencing postoperative complications such as urinary retention, but this comes after the assessment of vital signs.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following an abdominal hysterectomy. Maintaining adequate oxygenation is critical after anesthesia, as respiratory function can be compromised. The nurse must ensure the client's airway is clear and that they are receiving sufficient oxygen to prevent hypoxia and other respiratory complications.
Choice C reason:
Inspecting the abdominal dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.
Choice D reason:
Pain management is a significant part of postoperative care, and the nurse will need to assess the client's pain level to manage it effectively. However, the immediate priority is to ensure the client's vital signs are stable, which includes oxygen saturation, before addressing pain.
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