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. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.
B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.
C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.
D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.
Correct Answer is C
Explanation
A. While hydrogen peroxide has some disinfectant properties, it is not as effective as other agents like chlorine bleach for cleaning surfaces contaminated with blood.
B. Isopropyl alcohol is effective against many pathogens but may not be as effective as chlorine bleach specifically for bloodborne pathogens.
C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and other bodily fluids, as it has strong disinfectant properties.
D. Chlorhexidine is primarily used as an antiseptic for skin preparation and may not be as effective for surface cleaning of blood contamination.
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