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 A
Explanation
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.
Correct Answer is B
Explanation
A. Cannabis withdrawal typically presents with symptoms such as irritability, anxiety, insomnia, decreased appetite, and physical discomfort, but not constricted pupils, delayed reflexes, and decreased blood pressure.
B. Opioid intoxication can cause constricted pupils (miosis), delayed reflexes, and decreased blood pressure, among other symptoms such as respiratory depression, drowsiness, and altered mental status.
C. Amphetamine intoxication typically presents with symptoms such as dilated pupils, increased blood pressure, tachycardia, agitation, and hallucinations, but not constricted pupils, delayed reflexes, and decreased blood pressure.
D. Alcohol withdrawal typically presents with symptoms such as tremors, anxiety, agitation, hallucinations, increased heart rate and blood pressure, but not constricted pupils, delayed reflexes, and decreased blood pressure.
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