A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?
Massage the client's red bony prominences.
Assess the client's skin for increased coolness.
Reposition the client every 2 hr.
Keep the client's skin moist.
The Correct Answer is C
A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.
B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.
C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.
D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sanguineous drainage consists mostly of blood and is bright red, indicating active bleeding.
B. Serous drainage is clear or slightly yellowish and watery, often seen in healing wounds.
C. Serosanguineous drainage is a mixture of blood and serous fluid, which is watery with a pink or reddish tinge, common in early wound healing.
D. Purulent drainage is thick and cloudy, indicating infection, usually accompanied by an unpleasant odor.
Correct Answer is D
Explanation
A. Vitamin D is important for bone health but is not directly involved in wound healing.
B. Vitamin B1 (thiamine) is essential for energy metabolism but does not play a major role in wound healing.
C. Calcium is vital for bone health, but protein plays a more significant role in tissue repair.
D. Protein is essential for tissue regeneration and wound healing as it helps build and repair tissues.
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