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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Related Questions
Correct Answer is C
Explanation
A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.
B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.
C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.
D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical
incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.
Correct Answer is D
Explanation
A. Adjusting the straps on the harness once per week is not recommended. The straps should only be adjusted by a healthcare provider to ensure proper fit and alignment, as incorrect adjustments can compromise the effectiveness of the treatment.
B. Using ultra-thin diapers applied over the straps is incorrect. Diapers should be placed under the harness to prevent soiling and maintain the harness's effectiveness. Placing diapers over the straps can interfere with proper positioning.
C. Maintaining the child in a prone position while the harness is in place is not necessary. The Pavlik harness is designed to keep the hips in a flexed and abducted position, and the infant can remain in various positions that are comfortable and safe.
D. Gently massaging the skin under the straps once per day is correct. This helps prevent skin irritation and promotes circulation. Guardians should also check for redness or irritation and ensure the harness fits properly to avoid pressure injuries.
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