A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?
Encourage client fluid intake of 2,500 mL daily.
Moisturize dry skin areas on the client every other day.
Place a dehumidifier in the client's room.
Apply a donut ring pillow under the client's sacral area.
The Correct Answer is A
A.
A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.
B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.
C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.
D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
Correct Answer is A
Explanation
A.
A. Early decelerations are typically benign and occur due to head compression during
contractions. They mirror the uterine contraction pattern and are not usually associated with fetal compromise.
B. Fetal hypoxia is not typically associated with early decelerations, as they are considered a normal response to head compression during labor.
C. Abruptio placentae refers to the premature separation of the placenta from the uterine wall and is not directly related to early decelerations.
D. Postmaturity refers to a pregnancy that extends beyond 42 weeks gestation and is not directly related to early decelerations.
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