A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.

Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Elevate the head of the bed no more than 45°.

Use a transfer device to lift the client up in bed.

Massage the skin over the client's bony prominences.

Apply cornstarch to keep sensitive skin areas dry.

Answer and Explanation

The Correct Answer is A

A.   Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B.   Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C.   Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D.   Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.

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Correct Answer is D

Explanation

A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.

A. Administer an analgesic PO. B. Request a prescription for placement of a central venous access device. C. Administer a local anesthetic. D. Remove the catheter and insert another into a different site.

Correct Answer is D

Explanation

A. Administering an analgesic by mouth (PO) may not provide immediate relief for the pain at the insertion site. It is more effective to address the issue directly by repositioning the IV catheter.
B. Requesting a prescription for a central venous access device is not necessary in this situation. If peripheral IV access is indicated, the nurse should aim to find a suitable site for insertion.
C. Administering a local anesthetic may not be necessary if the pain is solely related to the insertion of the IV catheter. Repositioning the catheter to a more comfortable site is a more appropriate first step.
D. If the client reports pain at the insertion site after the IV catheter has been placed, it may indicate that the catheter is not properly positioned or may be causing discomfort. In this case, it is appropriate for the nurse to remove the catheter and select a different site for insertion.

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A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Nursing Test Bank

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A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.

Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?