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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.
B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.
C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care
activities.
D. Advise the client to leave the television in the room on when trying to fall asleep - Screen
time before bed can interfere with falling asleep due to the stimulating effect of light and content.
Correct Answer is A
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
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