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.

Answer and Explanation

The Correct Answer is 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.

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Correct Answer is D

Explanation

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

A. A client who has an ileal conduit and mucus in the pouch B. A client who has an arteriovenous fistula that vibrates when palpated C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag D. A client who has chronic kidney disease with cloudy dialysate outflow

Correct Answer is C

Explanation

A. A client who has an ileal conduit and mucus in the pouch - While mucus in the ileal conduit pouch should be monitored, it is not an urgent priority compared to assessing for potential complications such as bleeding in another client.

B. A client who has an arteriovenous fistula that vibrates when palpated - A vibrating arteriovenous fistula indicates normal functioning and does not require immediate assessment.

C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag - Red-tinged urine may indicate bleeding, a potential complication after a transurethral resection of the prostate, requiring prompt assessment and intervention.

D. A client who has chronic kidney disease with cloudy dialysate outflow - While cloudy dialysate outflow may indicate infection or other complications in a client with chronic kidney disease on peritoneal dialysis, it is not as urgent as assessing for bleeding in the client with red- tinged urine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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