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 B
Explanation
A. Diabetes mellitus is not a contraindication for methylergonovine, although blood glucose should be monitored in all postpartum clients.
B. Hypertension is a contraindication because methylergonovine causes vasoconstriction, which can dangerously elevate blood pressure and increase the risk of stroke or other cardiovascular complications.
C. Migraine headaches are not an absolute contraindication, although ergot derivatives can potentially exacerbate migraines in some clients.
D. Hepatitis B is not a contraindication, though liver function should be monitored when using medications metabolized by the liver.
Correct Answer is C
Explanation
A. Failure to engraft is characterized by the absence of new bone marrow cell growth, leading to persistent low blood counts. It does not typically present with skin peeling or desquamation.
B. Veno-occlusive disease primarily affects the liver and presents with symptoms such as weight gain, hepatomegaly, and jaundice. Skin desquamation is not a common manifestation of this complication.
C. Graft-versus-host disease commonly affects the skin, liver, and gastrointestinal tract, with early signs including rash and desquamation of the hands and feet. This finding is a hallmark indication of this complication following a bone marrow transplant.
D. Pancytopenia involves a reduction in red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding. It does not typically cause skin peeling.
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