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 A

Explanation

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

A. Take the client to the bathroom to void. B. Ask the client to verify the surgical site. C. Review deep breathing and coughing exercises. D. Raise the side rails on the bed.

Correct Answer is D

Explanation

A. Taking the client to the bathroom after a preoperative injection may be unsafe because many preoperative medications can cause sedation or dizziness, increasing the risk of falls.
B. Verification of the surgical site should occur before administration of preoperative medications, as the client may be sedated and unable to participate accurately afterward.
C. Teaching deep breathing and coughing exercises is most effective before sedation, when the client is alert and able to learn and follow instructions.
D. Raising the side rails on the bed is a priority safety measure after administering preoperative sedatives, as it helps prevent falls and injury while the client is drowsy or unsteady.

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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

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